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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
SC
SCDOI-MRF-CPT-88305
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South Carolina Department of Insurance (SCDOI) & CMS TiC Payer MRF Index
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Charleston County, SC
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Filing / IDR Window: 2026-11-19
SC Commercial Payer TiC MRF & Lab Reimbursement Cohort — CPT 88305 / 80053
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Pathology & Clinical Laboratory in SC (CPT 88305 Level IV Surgical Pathology & Out-of-Network Lab Payer MRF Rates).
Cohort MRF 75th-Pct Value
$1,915,000
Target % of Medicare
239.0% MPFS
Statutory Authority
SC-GPCI-2026 (S.C. Code Ann. § 38-59-230)
ERISA / Timely-Filing Window
90 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-63030 | Lumbar Laminotomy (Hemilaminectomy) with Decompression | CLAIM | 580 | $1,874.60 | $4,418.70 | $5,582.60 |
| CPT-22551 | Anterior Cervical Discectomy & Interbody Fusion (ACDF) | CLAIM | 165 | $2,718.17 | $6,407.11 | $8,094.77 |
| CPT-99214-25 | Level 4 Established Patient Outpatient E/M with Separately Identifiable Modifier 25 | CLAIM | 1,200 | $115.00 | $172.00 | $204.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Labtech Diagnostics CarolinasSC Regional Pathology Associates PASC Ambulatory Pathology Center LLC