SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/2/2016 9/30/2016 8/9/2016 12/27/2016 1374059 BOSSIER CITY FIRE DEPT EMS *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 232.07% $14,413.98 $8,202.88$14,413.98Ground mileage $6,211.10901901 100.00%0

A0427 232.07% $124,452.69 $70,825.38$124,452.69ALS1­emergency $53,627.31142142 100.00%142

A0429 232.07% $27,810.73 $15,826.96$27,810.73BLS­emergency $11,983.773838 100.00%38

A0433 232.07% $13,021.00 $7,410.20$13,021.00als 2 $5,610.801010 100.00%10

A0434 232.07% $1,538.83 $875.74$1,538.83Specialty care transport $663.0911 100.00%1

$181,237.23 $103,141.16$181,237.23$78,096.0710921092 100.00%191

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/3/2016 9/29/2016 8/9/2016 1/31/2017 1917656 BOSSIER PARISH EMERG MED SERV*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 207.20% $23,158.84 $11,981.79$23,158.84Ground mileage $11,177.0516731673 100.00%0

A0427 207.20% $54,971.32 $28,440.72$54,971.32ALS1­emergency $26,530.607272 100.00%72

A0429 207.20% $12,746.78 $6,594.84$12,746.78BLS­emergency $6,151.942020 100.00%20

A0433 207.20% $4,215.44 $2,180.96$4,215.44als 2 $2,034.4844 100.00%4

$95,092.38 $49,198.31$95,092.38$45,894.0717691769 100.00%96

Thursday, February 16, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/29/2016 8/9/2016 2/7/2017 1474886 EAST JEFFERSON MOBILE EMERGEN*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 155.39% $8,091.81 $2,884.30$8,091.81Ground mileage $5,207.51733733 100.00%0

A0427 155.39% $58,344.12 $20,797.18$58,344.12ALS1­emergency $37,546.949090 100.00%90

A0429 155.39% $22,363.20 $7,971.53$22,363.20BLS­emergency $14,391.674040 100.00%40

A0433 155.39% $1,868.00 $665.86$1,868.00als 2 $1,202.1422 100.00%2

$90,667.13 $32,318.87$90,667.13$58,348.26865865 100.00%132

Wednesday, February 22, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/28/2016 8/30/2016 1/3/2017 1337838 EMERGENCY MEDICAL SERVICE *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 209.55% $3,633.33 $1,899.48$3,633.33Ground mileage $1,733.85242242 100.00%0

A0427 209.55% $26,148.00 $13,669.80$26,148.00ALS1­emergency $12,478.203030 100.00%30

A0429 209.55% $19,829.13 $10,366.41$19,829.13BLS­emergency $9,462.722727 100.00%27

A0433 209.55% $1,261.53 $659.51$1,261.53als 2 $602.0211 100.00%1

$50,871.99 $26,595.20$50,871.99$24,276.79300300 100.00%58

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/9/2016 2/7/2017 1392278 SHREVEPORT FIRE DEPT/EMS *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 205.81% $38,454.49 $19,770.06$38,454.49Ground mileage $18,684.4327262726 100.00%0

A0427 205.81% $312,630.59 $160,727.56$312,630.59ALS1­emergency $151,903.03404404 100.00%404

A0429 205.81% $108,580.51 $55,823.10$108,580.51BLS­emergency $52,757.41167167 100.00%167

A0433 205.81% $33,288.88 $17,114.32$33,288.88als 2 $16,174.563030 100.00%30

$492,954.47 $253,435.04$492,954.47$239,519.4333273327 100.00%601

Wednesday, February 22, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: Criteria End:

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

$0.00 $0.00$0.00$0.0000 0

$0.00 $0.00$0.00$0.0000 0

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/9/2016 2/7/2017 1354023 CITY OF BATON ROUGE DEPT EMS *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 151.82% $39,156.78 $13,365.18$39,156.78Ground mileage $25,791.6036503650 100.00%0

A0427 151.82% $163,040.41 $55,650.64$163,040.41ALS1­emergency $107,389.77277277 100.00%277

A0429 151.82% $66,907.53 $22,837.12$66,907.53BLS­emergency $44,070.41135135 100.00%135

A0433 151.82% $1,703.66 $581.50$1,703.66als 2 $1,122.1622 100.00%2

$270,808.38 $92,434.44$270,808.38$178,373.9440644064 100.00%414

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 7/26/2016 2/7/2017 1304905 EMERGENCY MED SERV­CITY/N O *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 272.52% $76,254.05 $48,272.95$76,254.05Ground mileage $27,981.1039803980 100.00%0

A0427 272.52% $848,009.01 $536,835.96$848,009.01ALS1­emergency $311,173.05748748 100.00%748

A0429 272.52% $32,461.27 $20,549.77$32,461.27BLS­emergency $11,911.503434 100.00%34

A0433 272.52% $22,968.68 $14,540.40$22,968.68als 2 $8,428.281414 100.00%14

$979,693.01 $620,199.08$979,693.01$359,493.9347764776 100.00%796

Thursday, June 1, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/2/2016 9/29/2016 8/2/2016 1/31/2017 1309591 ALLEN PARISH AMBULANCE SERVIC*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 238.33% $33,916.49 $19,685.60$33,916.49Ground mileage $14,230.8915431543 100.00%0

A0427 238.33% $58,585.61 $34,003.82$58,585.61ALS1­emergency $24,581.796363 100.00%63

A0433 238.33% $2,700.66 $1,567.50$2,700.66als 2 $1,133.1622 100.00%2

A0434 238.33% $4,787.49 $2,778.72$4,787.49Specialty care transport $2,008.7733 100.00%3

$99,990.25 $58,035.64$99,990.25$41,954.6116111611 100.00%68

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/11/2016 9/28/2016 8/16/2016 11/15/2016 1471585 CADDO FIRE DISTRICT #1 *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 233.52% $4,248.09 $2,428.93$4,248.09Ground mileage $1,819.16257257 100.00%0

A0427 233.52% $12,673.64 $7,246.40$12,673.64ALS1­emergency $5,427.241414 100.00%14

A0429 233.52% $3,811.50 $2,179.30$3,811.50BLS­emergency $1,632.2055 100.00%5

$20,733.23 $11,854.63$20,733.23$8,878.60276276 100.00%19

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/23/2016 1/3/2017 1550426 JACKSON PARISH AMBULANCE SERV*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 147.71% $24,476.32 $7,905.88$24,476.32Ground mileage $16,570.4418911891 100.00%0

A0427 147.71% $52,756.85 $17,040.13$52,756.85ALS1­emergency $35,716.727575 100.00%75

A0429 147.71% $20,194.72 $6,522.95$20,194.72BLS­emergency $13,671.773434 100.00%34

A0433 147.71% $2,888.98 $933.14$2,888.98als 2 $1,955.8433 100.00%3

$100,316.87 $32,402.10$100,316.87$67,914.7720032003 100.00%112

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/3/2016 9/30/2016 8/2/2016 11/15/2016 1920932 W CARROLL VOLUNTEER EMERG MED*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 179.96% $23,412.12 $10,402.49$23,412.12Ground mileage $13,009.6315971597 100.00%0

A0427 179.96% $25,519.43 $11,338.75$25,519.43ALS1­emergency $14,180.683636 100.00%36

A0429 179.96% $11,271.18 $5,008.02$11,271.18BLS­emergency $6,263.161919 100.00%19

$60,202.73 $26,749.26$60,202.73$33,453.4716521652 100.00%55

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/2/2016 9/27/2016 8/16/2016 11/1/2016 1137227 CADDO PARISH FIRE DISTRICT #4*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 206.64% $2,385.57 $1,231.12$2,385.57Ground mileage $1,154.45171171 100.00%0

A0427 206.64% $9,163.35 $4,728.90$9,163.35ALS1­emergency $4,434.451212 100.00%12

$11,548.92 $5,960.02$11,548.92$5,588.90183183 100.00%12

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/29/2016 8/16/2016 11/15/2016 1193925 LAFOURCHE AMBULANCE *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 184.47% $20,516.19 $9,394.48$20,516.19Ground mileage $11,121.7112741274 100.00%0

A0427 184.47% $31,093.97 $14,238.17$31,093.97ALS1­emergency $16,855.804343 100.00%43

A0429 184.47% $4,851.95 $2,221.75$4,851.95BLS­emergency $2,630.2088 100.00%8

$56,462.11 $25,854.40$56,462.11$30,607.7113251325 100.00%51

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/7/2016 9/26/2016 8/23/2016 12/6/2016 1955922 CADDO PARISH FIRE DISTRICT #3*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 196.91% $2,457.47 $1,209.45$2,457.47Ground mileage $1,248.02173173 100.00%0

A0427 196.91% $7,360.33 $3,622.41$7,360.33ALS1­emergency $3,737.921010 100.00%10

A0429 196.91% $1,938.83 $954.20$1,938.83BLS­emergency $984.6333 100.00%3

$11,756.63 $5,786.06$11,756.63$5,970.57186186 100.00%13

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/2/2016 1/31/2017 1122459 RUSTON LINCOLN AMB SERV *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 190.79% $6,699.05 $3,187.87$6,699.05Ground mileage $3,511.18335335 100.00%0

A0427 190.79% $33,776.86 $16,073.23$33,776.86ALS1­emergency $17,703.634646 100.00%46

A0429 190.79% $28,599.27 $13,609.36$28,599.27BLS­emergency $14,989.914747 100.00%47

A0433 190.79% $3,023.22 $1,438.64$3,023.22als 2 $1,584.5833 100.00%3

$72,098.40 $34,309.10$72,098.40$37,789.30431431 100.00%96

Thursday, June 1, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 7/19/2016 2/7/2017 1676896 A MED AMBULANCE INC * *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 129.76% $26,827.41 $787.40$21,462.03Ground mileage $20,674.6329582958 80.00%0

A0427 129.76% $197,509.03 $5,796.57$158,008.51ALS1­emergency $152,211.94367367 80.00%367

A0429 129.76% $62,076.49 $1,821.94$49,661.18BLS­emergency $47,839.24137137 80.00%137

A0434 129.76% $4,616.10 $135.50$3,692.90Specialty care transport $3,557.4055 80.00%5

$291,029.03 $8,541.41$232,824.62$224,283.2134673467 80.00%509

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 7/26/2016 1/31/2017 1196878 ACADIAN AMBULANCE NEW ORLEANS*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 233.36% $54,399.23 $20,208.18$43,519.48Ground mileage $23,311.3032743274 80.00%0

A0427 233.36% $345,462.53 $128,331.29$276,369.39ALS1­emergency $148,038.10358358 80.00%358

A0429 233.36% $132,603.36 $49,259.90$106,083.24BLS­emergency $56,823.34163163 80.00%163

A0433 233.36% $15,380.89 $5,713.68$12,304.75als 2 $6,591.071111 80.00%11

A0434 233.36% $33,093.28 $12,293.45$26,474.66Specialty care transport $14,181.212020 80.00%20

$580,939.29 $215,806.50$464,751.52$248,945.0238263826 80.00%552

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 7/19/2016 2/7/2017 1118214 ACADIAN AMBULANCE SERVICE *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 242.75% $1,550,971.15 $601,861.10$1,240,777.60Ground mileage $638,916.508025080250 80.00%0

A0427 242.75% $5,335,903.72 $2,070,595.49$4,268,712.69ALS1­emergency $2,198,117.2056565656 80.00%5656

A0429 242.75% $1,322,153.51 $513,060.37$1,057,718.46BLS­emergency $544,658.0916651665 80.00%1665

A0431 242.75% $447,997.49 $173,847.03$358,397.96Rotary wing air transport $184,550.934747 80.00%47

A0433 242.75% $169,036.41 $65,595.56$135,229.61als 2 $69,634.05124124 80.00%124

A0434 242.75% $303,561.85 $117,798.01$242,849.28Specialty care transport $125,051.27187187 80.00%187

A0436 242.75% $114,067.17 $44,264.16$91,253.74Rotary wing air mileage $46,989.5817851785 80.00%0

$9,243,691.30 $3,587,021.72$7,394,939.34$3,807,917.628971489714 80.00%7679

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 7/26/2016 1/24/2017 1566691 ADVANCED EMERGENCY MEDICAL SE*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 195.33% $90,307.42 $26,012.40$72,245.71Ground mileage $46,233.3153195319 80.00%0

A0427 195.33% $190,081.51 $54,752.72$152,065.53ALS1­emergency $97,312.81220220 80.00%220

A0429 195.33% $92,387.49 $26,612.09$73,910.04BLS­emergency $47,297.95128128 80.00%128

$372,776.42 $107,377.21$298,221.28$190,844.0756675667 80.00%348

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/20/2016 9/7/2016 10/18/2016 1/31/2017 2152271 AIR EVAC EMS INC *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0431 456.12% $66,097.45 $38,386.73$52,877.97Rotary wing air transport $14,491.2433 80.00%3

A0436 456.12% $38,370.82 $22,284.21$30,696.65Rotary wing air mileage $8,412.44251251 80.00%0

$104,468.27 $60,670.94$83,574.62$22,903.68254254 80.00%3

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

9/22/2016 9/23/2016 10/25/2016 1/24/2017 2145223 AIR EVAC EMS INC *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0431 402.90% $19,541.13 $10,782.78$15,632.90Rotary wing air transport $4,850.1211 80.00%1

A0436 402.90% $7,890.11 $4,353.76$6,312.09Rotary wing air mileage $1,958.335959 80.00%0

$27,431.24 $15,136.54$21,944.99$6,808.456060 80.00%1

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 7/26/2016 2/7/2017 1368288 BALENTINE AMBUL SERVICE INC *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 138.48% $17,152.77 $1,335.71$13,722.28Ground mileage $12,386.5717901790 80.00%0

A0427 138.48% $204,056.52 $15,888.82$163,243.73ALS1­emergency $147,354.91381381 80.00%381

A0434 138.48% $4,591.25 $357.55$3,673.00Specialty care transport $3,315.4555 80.00%5

$225,800.54 $17,582.08$180,639.01$163,056.9321762176 80.00%386

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/4/2016 7/21/2016 8/23/2016 12/6/2016 1805971 CADDO PARISH FIRE DISTRICT #5*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 161.66% $372.00 $67.49$297.60Ground mileage $230.113232 80.00%0

A0427 161.66% $1,880.07 $341.07$1,504.05ALS1­emergency $1,162.9833 80.00%3

A0429 161.66% $527.72 $95.74$422.18BLS­emergency $326.4411 80.00%1

A0433 161.66% $907.04 $164.55$725.63als 2 $561.0811 80.00%1

$3,686.83 $668.85$2,949.46$2,280.613737 80.00%5

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/6/2016 9/9/2016 8/23/2016 10/25/2016 1409278 CADDO PARISH FIRE DISTRICT #6*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 154.08% $880.33 $132.91$704.26Ground mileage $571.358181 80.00%0

A0427 154.08% $4,181.17 $631.33$3,344.95ALS1­emergency $2,713.6277 80.00%7

A0429 154.08% $1,005.96 $151.88$804.76BLS­emergency $652.8822 80.00%2

A0433 154.08% $864.51 $130.53$691.61als 2 $561.0811 80.00%1

$6,931.97 $1,046.65$5,545.58$4,498.939191 80.00%10

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/14/2016 9/4/2016 9/6/2016 12/27/2016 1982351 CAMERON PRSH AMB SERV DIST #2*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 144.17% $997.79 $106.14$798.23Ground mileage $692.098181 80.00%0

A0427 144.17% $1,383.84 $147.22$1,107.08ALS1­emergency $959.8622 80.00%2

A0429 144.17% $941.26 $100.12$753.00BLS­emergency $652.8822 80.00%2

$3,322.89 $353.48$2,658.31$2,304.838585 80.00%4

Wednesday, February 22, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/6/2016 9/28/2016 8/16/2016 1/31/2017 1008745 CITY OF GONZALES FIRE/RESCUE *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 146.19% $1,559.16 $180.76$1,247.31Ground mileage $1,066.55154154 80.00%0

A0427 146.19% $11,785.94 $1,366.76$9,428.83ALS1­emergency $8,062.072121 80.00%21

A0429 146.19% $4,111.45 $476.77$3,289.18BLS­emergency $2,812.4199 80.00%9

$17,456.55 $2,024.29$13,965.32$11,941.03184184 80.00%30

Wednesday, February 22, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 9/20/2016 1/24/2017 1392006 CITY OF WESTWEGO E M S *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 213.92% $2,692.93 $895.45$2,154.31Ground mileage $1,258.86174174 80.00%0

A0427 213.92% $12,456.92 $4,142.32$9,965.48ALS1­emergency $5,823.161414 80.00%14

A0429 213.92% $16,484.16 $5,481.52$13,187.24BLS­emergency $7,705.722222 80.00%22

$31,634.01 $10,519.29$25,307.03$14,787.74210210 80.00%36

Wednesday, February 22, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/3/2016 9/29/2016 8/9/2016 1/24/2017 1138002 DESOTO PARISH EMS *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 152.40% $17,921.81 $2,577.68$14,337.41Ground mileage $11,759.7317521752 80.00%0

A0427 152.40% $19,881.84 $2,859.66$15,905.52ALS1­emergency $13,045.863333 80.00%33

A0429 152.40% $25,996.36 $3,739.06$20,797.14BLS­emergency $17,058.085252 80.00%52

$63,800.01 $9,176.40$51,040.07$41,863.6718371837 80.00%85

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/2/2016 2/7/2017 1951277 MED EXPRESS AMBULANCE SERV IN*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 164.59% $127,577.19 $24,549.06$102,061.54Ground mileage $77,512.4890559055 80.00%0

A0427 164.59% $150,519.65 $28,964.91$120,415.84ALS1­emergency $91,450.93213213 80.00%213

A0429 164.59% $103,541.55 $19,924.15$82,833.31BLS­emergency $62,909.16184184 80.00%184

A0433 164.59% $2,797.59 $538.32$2,238.06als 2 $1,699.7433 80.00%3

$384,435.98 $73,976.44$307,548.75$233,572.3194559455 80.00%400

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/9/2016 2/7/2017 1996220 MED LIFE EMERGENCY MED SERVS *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 149.62% $31,680.73 $4,170.63$25,344.66Ground mileage $21,174.0322342234 80.00%0

A0427 149.62% $73,796.94 $9,714.60$59,037.30ALS1­emergency $49,322.70126126 80.00%126

A0429 149.62% $24,167.29 $3,181.57$19,333.93BLS­emergency $16,152.364949 80.00%49

A0433 149.62% $5,086.32 $669.60$4,069.08als 2 $3,399.4866 80.00%6

$134,731.28 $17,736.40$107,784.97$90,048.5724152415 80.00%181

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/3/2016 9/30/2016 8/9/2016 11/15/2016 1893421 MED­TRANS CORPORATION *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0431 431.29% $104,590.40 $59,421.70$83,672.30Rotary wing air transport $24,250.6055 80.00%5

A0436 431.29% $36,888.44 $20,957.70$29,510.75Rotary wing air mileage $8,553.05256256 80.00%0

$141,478.84 $80,379.40$113,183.05$32,803.65261261 80.00%5

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/2/2016 2/7/2017 1991988 METRO AMBULANCE SERV RURAL IN*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 198.69% $60,428.84 $17,929.30$48,343.00Ground mileage $30,413.7041684168 80.00%0

A0427 198.69% $363,290.99 $107,788.52$290,632.02ALS1­emergency $182,843.50470470 80.00%470

A0429 198.69% $134,303.91 $39,848.07$107,443.14BLS­emergency $67,595.07207207 80.00%207

A0433 198.69% $3,355.36 $995.55$2,684.29als 2 $1,688.7433 80.00%3

$561,379.10 $166,561.44$449,102.45$282,541.0148484848 80.00%680

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/2/2016 2/7/2017 1560782 NORTHEAST LOUISIANA AMBULANCE*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 177.53% $139,592.45 $33,043.44$111,673.78Ground mileage $78,630.3488518851 80.00%0

A0427 177.53% $291,651.57 $69,038.27$233,321.38ALS1­emergency $164,283.11385385 80.00%385

A0429 177.53% $5,210.72 $1,233.48$4,168.60BLS­emergency $2,935.1288 80.00%8

A0433 177.53% $1,233.18 $291.91$986.54als 2 $694.6311 80.00%1

$437,687.92 $103,607.10$350,150.30$246,543.2092459245 80.00%394

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 7/19/2016 1/3/2017 1463698 NORTHSHORE EMS LLC *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 187.20% $59,985.25 $15,944.64$47,988.16Ground mileage $32,043.5234013401 80.00%0

A0427 187.20% $168,570.85 $44,807.18$134,856.24ALS1­emergency $90,049.06230230 80.00%230

A0429 187.20% $49,951.83 $13,277.80$39,961.30BLS­emergency $26,683.508181 80.00%81

A0433 187.20% $6,363.84 $1,691.58$5,091.06als 2 $3,399.4866 80.00%6

A0434 187.20% $3,760.41 $999.57$3,008.34Specialty care transport $2,008.7733 80.00%3

$288,632.18 $76,720.77$230,905.10$154,184.3337213721 80.00%320

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/1/2016 9/30/2016 8/2/2016 2/7/2017 1558176 PAFFORD EMERGENCY MEDICAL SER*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 225.01% $131,765.33 $46,852.26$105,411.94Ground mileage $58,559.6862896289 80.00%0

A0427 225.01% $376,586.48 $133,904.33$301,268.83ALS1­emergency $167,364.50378378 80.00%378

A0429 225.01% $70,260.75 $24,983.26$56,208.84BLS­emergency $31,225.588585 80.00%85

A0431 225.01% $47,290.72 $16,815.43$37,832.59Rotary wing air transport $21,017.1655 80.00%5

A0433 225.01% $15,053.64 $5,352.70$12,042.90als 2 $6,690.201010 80.00%10

A0434 225.01% $61,338.44 $21,810.32$49,070.70Specialty care transport $27,260.383838 80.00%38

A0436 225.01% $39,354.09 $13,993.33$31,483.26Rotary wing air mileage $17,489.93586586 80.00%0

$741,649.45 $263,711.63$593,319.06$329,607.4373917391 80.00%516

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/2/2016 9/27/2016 8/9/2016 2/7/2017 2118595 RED RIVER PARISH EMS *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 170.18% $9,952.00 $2,113.71$7,961.65Ground mileage $5,847.94668668 80.00%0

A0427 170.18% $37,238.02 $7,908.64$29,790.32ALS1­emergency $21,881.684646 80.00%46

A0429 170.18% $3,986.85 $846.79$3,189.50BLS­emergency $2,342.7166 80.00%6

A0433 170.18% $1,182.12 $251.07$945.70als 2 $694.6311 80.00%1

$52,358.99 $11,120.21$41,887.17$30,766.96721721 80.00%53

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: 07/01/2016 Criteria End: 09/30/2016

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/2/2016 9/24/2016 8/9/2016 10/25/2016 1110779 ST TAMMANY FIRE DISTRICT 11 *

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

A0425 179.99% $1,021.99 $249.79$817.59Ground mileage $567.808282 80.00%0

A0427 179.99% $6,279.75 $1,534.86$5,023.80ALS1­emergency $3,488.9499 80.00%9

A0429 179.99% $589.43 $144.06$471.54BLS­emergency $327.4811 80.00%1

A0433 179.99% $1,009.89 $246.83$807.91als 2 $561.0811 80.00%1

$8,901.06 $2,175.54$7,120.84$4,945.309393 80.00%11

Wednesday, February 15, 2017 Page 1 of 1

SupplementalPaymentCrossoveratFullCap(LargeUrban­100%,Non­80%)

Criteria Begin: Criteria End:

Medicaid Payer: Medicaid Traditional/Shared

First DOS Last DOS First Payment Date Last Payment Date Billing Provider Number Billing Provider Name

7/3/2016 9/28/2016 7/26/2016 2/7/2017 1474860 WEST JEFFERSON MEDICAL CENTER*

CPT Code ACR Conversion Factor

Payment Ceiling {Medicare

Conversion Factor x Medicare

Allowed Amount}

Net Supplemental Payment

{Reduced Amt for Non-Lug Gov't

Status - Medicare Allowed}

Reduced Amount for Non-

Large Urban Gov't Status

Short Descriptor Medicare Allowed

{Medicare Payment + Ded Coin}

Actual UnitsUnit of Service Cap %Trip Count

$0.00 $0.00$0.00$0.0000 0

$0.00 $0.00$0.00$0.0000 0

Wednesday, February 15, 2017 Page 1 of 1