/data /row/code_description /row/code_type /row/code /row/de_identified_maximum_negotiated_charge /row/de_identified_maximum_negotiated_charge/#agg /row/de_identified_minimum_negotiated_charge /row/de_identified_minimum_negotiated_charge/#agg /row/discounted_cash_price /row/discounted_cash_price/#agg /row/gross_charge /row/gross_charge/#agg /row/patient_class /row/payer_specific_negotiated_charge /row/payer_specific_negotiated_charge/#agg /row/payer /row/plan_type "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 aetna ppo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 aetna epo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 aetna hmo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 aetna pos "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1732.38 1732.38 aetna ppo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1732.38 1732.38 aetna epo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1732.38 1732.38 aetna hmo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1732.38 1732.38 aetna pos "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 325.48 325.48 aetna ppo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 325.48 325.48 aetna epo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 325.48 325.48 aetna hmo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 325.48 325.48 aetna pos CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 739.85 739.85 aetna ppo CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 739.85 739.85 aetna epo CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 739.85 739.85 aetna hmo CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 739.85 739.85 aetna pos methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 1406.03 1406.03 aetna ppo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 1406.03 1406.03 aetna epo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 1406.03 1406.03 aetna hmo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 1406.03 1406.03 aetna pos "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 903.1 903.1 aetna ppo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 903.1 903.1 aetna epo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 903.1 903.1 aetna hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 903.1 903.1 aetna pos methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1995.04 1995.04 aetna ppo methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1995.04 1995.04 aetna epo methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1995.04 1995.04 aetna hmo methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1995.04 1995.04 aetna pos Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2177.79 2177.79 aetna ppo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2177.79 2177.79 aetna epo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2177.79 2177.79 aetna hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2177.79 2177.79 aetna pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1138.95 1138.95 aetna ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1138.95 1138.95 aetna epo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1138.95 1138.95 aetna hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1138.95 1138.95 aetna pos "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna ppo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna epo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna hmo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 23.3 23.3 aetna ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 23.3 23.3 aetna epo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 23.3 23.3 aetna hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 23.3 23.3 aetna pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 825.72 825.72 aetna ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 825.72 825.72 aetna epo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 825.72 825.72 aetna hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 825.72 825.72 aetna pos perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 14191.44 14191.44 aetna ppo perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 14191.44 14191.44 aetna epo perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 14191.44 14191.44 aetna hmo perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 14191.44 14191.44 aetna pos Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 50.06 50.06 aetna ppo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 50.06 50.06 aetna epo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 50.06 50.06 aetna hmo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 50.06 50.06 aetna pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 22.94 22.94 aetna ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 22.94 22.94 aetna epo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 22.94 22.94 aetna hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 22.94 22.94 aetna pos "kcentra, per i.u." cpt C9132 4893.99 4893.99 1444.99 1444.99 25616.82 25616.82 21347.35 21347.35 O 1444.99 1444.99 aetna ppo "kcentra, per i.u." cpt C9132 4893.99 4893.99 1444.99 1444.99 25616.82 25616.82 21347.35 21347.35 O 1444.99 1444.99 aetna epo "kcentra, per i.u." cpt C9132 4893.99 4893.99 1444.99 1444.99 25616.82 25616.82 21347.35 21347.35 O 1444.99 1444.99 aetna hmo "kcentra, per i.u." cpt C9132 4893.99 4893.99 1444.99 1444.99 25616.82 25616.82 21347.35 21347.35 O 1444.99 1444.99 aetna pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1971.24 1971.24 aetna ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1971.24 1971.24 aetna epo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1971.24 1971.24 aetna hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1971.24 1971.24 aetna pos Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 663.49 663.49 aetna ppo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 663.49 663.49 aetna epo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 663.49 663.49 aetna hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 663.49 663.49 aetna pos "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 63.7 63.7 aetna ppo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 63.7 63.7 aetna epo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 63.7 63.7 aetna hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 63.7 63.7 aetna pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1743.68 1743.68 aetna ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1743.68 1743.68 aetna epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1743.68 1743.68 aetna hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1743.68 1743.68 aetna pos Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 1516.11 1516.11 aetna ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 1516.11 1516.11 aetna epo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 1516.11 1516.11 aetna hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 1516.11 1516.11 aetna pos "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.29 70.29 aetna ppo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.29 70.29 aetna epo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.29 70.29 aetna hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.29 70.29 aetna pos Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 aetna ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 aetna epo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 aetna hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 aetna pos Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 87.99 87.99 aetna ppo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 87.99 87.99 aetna epo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 87.99 87.99 aetna hmo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 87.99 87.99 aetna pos Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 83.8 83.8 aetna ppo Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 83.8 83.8 aetna epo Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 83.8 83.8 aetna hmo Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 83.8 83.8 aetna pos Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 46.48 46.48 aetna ppo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 46.48 46.48 aetna epo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 46.48 46.48 aetna hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 46.48 46.48 aetna pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 1464.23 1464.23 aetna ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 1464.23 1464.23 aetna epo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 1464.23 1464.23 aetna hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 1464.23 1464.23 aetna pos CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 aetna ppo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 aetna epo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 aetna hmo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 aetna pos General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 9490.45 9490.45 aetna ppo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 9490.45 9490.45 aetna epo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 9490.45 9490.45 aetna hmo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 9490.45 9490.45 aetna pos Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1995.04 1995.04 aetna ppo Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1995.04 1995.04 aetna epo Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1995.04 1995.04 aetna hmo Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1995.04 1995.04 aetna pos CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 671.68 671.68 aetna ppo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 671.68 671.68 aetna epo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 671.68 671.68 aetna hmo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 671.68 671.68 aetna pos Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna ppo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna epo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna pos Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna ppo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna epo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 620.75 620.75 aetna pos Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1995.04 1995.04 aetna ppo Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1995.04 1995.04 aetna epo Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1995.04 1995.04 aetna hmo Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1995.04 1995.04 aetna pos "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 9214.1 9214.1 aetna ppo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 9214.1 9214.1 aetna epo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 9214.1 9214.1 aetna hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 9214.1 9214.1 aetna pos cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7205.71 7205.71 aetna ppo cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7205.71 7205.71 aetna epo cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7205.71 7205.71 aetna hmo cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7205.71 7205.71 aetna pos MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 1807.46 1807.46 aetna ppo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 1807.46 1807.46 aetna epo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 1807.46 1807.46 aetna hmo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 1807.46 1807.46 aetna pos Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1264.62 1264.62 aetna ppo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1264.62 1264.62 aetna epo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1264.62 1264.62 aetna hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1264.62 1264.62 aetna pos "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 2410.83 2410.83 aetna ppo "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 2410.83 2410.83 aetna epo "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 2410.83 2410.83 aetna hmo "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 2410.83 2410.83 aetna pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 aetna ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 aetna epo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 aetna hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 aetna pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1127.01 1127.01 aetna ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1127.01 1127.01 aetna epo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1127.01 1127.01 aetna hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1127.01 1127.01 aetna pos "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 620.75 620.75 aetna ppo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 620.75 620.75 aetna epo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 620.75 620.75 aetna hmo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 620.75 620.75 aetna pos ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 249.2 249.2 aetna ppo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 249.2 249.2 aetna epo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 249.2 249.2 aetna hmo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 249.2 249.2 aetna pos regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1958.83 1958.83 aetna ppo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1958.83 1958.83 aetna epo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1958.83 1958.83 aetna hmo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1958.83 1958.83 aetna pos "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 105.94 105.94 aetna ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 105.94 105.94 aetna epo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 105.94 105.94 aetna hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 105.94 105.94 aetna pos Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 385.25 385.25 aetna ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 385.25 385.25 aetna epo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 385.25 385.25 aetna hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 385.25 385.25 aetna pos "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14156.17 14156.17 aetna ppo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14156.17 14156.17 aetna epo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14156.17 14156.17 aetna hmo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14156.17 14156.17 aetna pos "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 643.93 643.93 aetna ppo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 643.93 643.93 aetna epo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 643.93 643.93 aetna hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 643.93 643.93 aetna pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 579.75 579.75 aetna ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 579.75 579.75 aetna epo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 579.75 579.75 aetna hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 579.75 579.75 aetna pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 573.24 573.24 aetna ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 573.24 573.24 aetna epo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 573.24 573.24 aetna hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 573.24 573.24 aetna pos CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 aetna ppo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 aetna epo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 aetna hmo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 aetna pos metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 9490.45 9490.45 aetna ppo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 9490.45 9490.45 aetna epo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 9490.45 9490.45 aetna hmo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 9490.45 9490.45 aetna pos Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 aetna ppo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 aetna epo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 aetna hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 aetna pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8619.47 8619.47 aetna ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8619.47 8619.47 aetna epo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8619.47 8619.47 aetna hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8619.47 8619.47 aetna pos embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14120.9 14120.9 aetna ppo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14120.9 14120.9 aetna epo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14120.9 14120.9 aetna hmo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14120.9 14120.9 aetna pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11450.77 11450.77 aetna ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11450.77 11450.77 aetna epo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11450.77 11450.77 aetna hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11450.77 11450.77 aetna pos "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 14120.9 14120.9 aetna ppo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 14120.9 14120.9 aetna epo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 14120.9 14120.9 aetna hmo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 14120.9 14120.9 aetna pos neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 4282.09 4282.09 aetna ppo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 4282.09 4282.09 aetna epo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 4282.09 4282.09 aetna hmo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 4282.09 4282.09 aetna pos CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 160.63 160.63 aetna ppo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 160.63 160.63 aetna epo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 160.63 160.63 aetna hmo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 160.63 160.63 aetna pos "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 14156.17 14156.17 aetna ppo "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 14156.17 14156.17 aetna epo "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 14156.17 14156.17 aetna hmo "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 14156.17 14156.17 aetna pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 377.12 377.12 aetna ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 377.12 377.12 aetna epo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 377.12 377.12 aetna hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 377.12 377.12 aetna pos "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 1493.86 1493.86 aetna ppo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 1493.86 1493.86 aetna epo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 1493.86 1493.86 aetna hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 1493.86 1493.86 aetna pos "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 2147.64 2147.64 aetna ppo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 2147.64 2147.64 aetna epo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 2147.64 2147.64 aetna hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 2147.64 2147.64 aetna pos Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 737.44 737.44 aetna ppo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 737.44 737.44 aetna epo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 737.44 737.44 aetna hmo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 737.44 737.44 aetna pos "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 aetna ppo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 aetna epo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 aetna hmo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 aetna pos "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 1218.97 1218.97 aetna ppo "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 1218.97 1218.97 aetna epo "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 1218.97 1218.97 aetna hmo "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 1218.97 1218.97 aetna pos vinblastine sulfate inj cpt J9360 10076.53 10076.53 758.2 758.2 5234.28 5234.28 4361.9 4361.9 O 10076.53 10076.53 aetna ppo vinblastine sulfate inj cpt J9360 10076.53 10076.53 758.2 758.2 5234.28 5234.28 4361.9 4361.9 O 10076.53 10076.53 aetna epo vinblastine sulfate inj cpt J9360 10076.53 10076.53 758.2 758.2 5234.28 5234.28 4361.9 4361.9 O 10076.53 10076.53 aetna hmo vinblastine sulfate inj cpt J9360 10076.53 10076.53 758.2 758.2 5234.28 5234.28 4361.9 4361.9 O 10076.53 10076.53 aetna pos Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 430.19 430.19 aetna ppo Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 430.19 430.19 aetna epo Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 430.19 430.19 aetna hmo Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 430.19 430.19 aetna pos "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 9249.37 9249.37 741.72 741.72 37090.75 37090.75 30908.96 30908.96 O 9249.37 9249.37 aetna ppo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 9249.37 9249.37 741.72 741.72 37090.75 37090.75 30908.96 30908.96 O 9249.37 9249.37 aetna epo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 9249.37 9249.37 741.72 741.72 37090.75 37090.75 30908.96 30908.96 O 9249.37 9249.37 aetna hmo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 9249.37 9249.37 741.72 741.72 37090.75 37090.75 30908.96 30908.96 O 9249.37 9249.37 aetna pos "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 aetna ppo "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 aetna epo "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 aetna hmo "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 aetna pos Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 aetna ppo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 aetna epo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 aetna hmo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 aetna pos Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 4307.3 4307.3 aetna ppo Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 4307.3 4307.3 aetna epo Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 4307.3 4307.3 aetna hmo Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 4307.3 4307.3 aetna pos CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1297.13 1297.13 aetna ppo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1297.13 1297.13 aetna epo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1297.13 1297.13 aetna hmo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1297.13 1297.13 aetna pos CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1180.24 1180.24 aetna ppo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1180.24 1180.24 aetna epo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1180.24 1180.24 aetna hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1180.24 1180.24 aetna pos Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1156.19 1156.19 aetna ppo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1156.19 1156.19 aetna epo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1156.19 1156.19 aetna hmo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1156.19 1156.19 aetna pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 14191.44 14191.44 aetna ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 14191.44 14191.44 aetna epo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 14191.44 14191.44 aetna hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 14191.44 14191.44 aetna pos guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 9214.1 9214.1 aetna ppo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 9214.1 9214.1 aetna epo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 9214.1 9214.1 aetna hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 9214.1 9214.1 aetna pos "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 7408.69 7408.69 aetna ppo "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 7408.69 7408.69 aetna epo "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 7408.69 7408.69 aetna hmo "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 7408.69 7408.69 aetna pos Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 220.14 220.14 aetna ppo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 220.14 220.14 aetna epo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 220.14 220.14 aetna hmo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 220.14 220.14 aetna pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 998.76 998.76 aetna ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 998.76 998.76 aetna epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 998.76 998.76 aetna hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 998.76 998.76 aetna pos palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4124.09 4124.09 aetna ppo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4124.09 4124.09 aetna epo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4124.09 4124.09 aetna hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4124.09 4124.09 aetna pos Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 347.84 347.84 aetna ppo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 347.84 347.84 aetna epo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 347.84 347.84 aetna hmo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 347.84 347.84 aetna pos CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 2547.88 2547.88 aetna ppo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 2547.88 2547.88 aetna epo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 2547.88 2547.88 aetna hmo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 2547.88 2547.88 aetna pos ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2995.71 2995.71 aetna ppo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2995.71 2995.71 aetna epo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2995.71 2995.71 aetna hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2995.71 2995.71 aetna pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 aetna ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 aetna epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 aetna hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 aetna pos "conn tiss, non-human" cpt C1763 10542.6 10542.6 9490.45 9490.45 54305.62 54305.62 45254.68 45254.68 O 9490.45 9490.45 aetna ppo "conn tiss, non-human" cpt C1763 10542.6 10542.6 9490.45 9490.45 54305.62 54305.62 45254.68 45254.68 O 9490.45 9490.45 aetna epo "conn tiss, non-human" cpt C1763 10542.6 10542.6 9490.45 9490.45 54305.62 54305.62 45254.68 45254.68 O 9490.45 9490.45 aetna hmo "conn tiss, non-human" cpt C1763 10542.6 10542.6 9490.45 9490.45 54305.62 54305.62 45254.68 45254.68 O 9490.45 9490.45 aetna pos "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 aetna ppo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 aetna epo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 aetna hmo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 aetna pos "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 4307.3 4307.3 aetna ppo "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 4307.3 4307.3 aetna epo "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 4307.3 4307.3 aetna hmo "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 4307.3 4307.3 aetna pos Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 819.35 819.35 aetna ppo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 819.35 819.35 aetna epo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 819.35 819.35 aetna hmo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 819.35 819.35 aetna pos MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.32 206.32 aetna ppo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.32 206.32 aetna epo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.32 206.32 aetna hmo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.32 206.32 aetna pos simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9778.82 9778.82 aetna ppo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9778.82 9778.82 aetna epo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9778.82 9778.82 aetna hmo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9778.82 9778.82 aetna pos ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 1862.34 1862.34 aetna ppo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 1862.34 1862.34 aetna epo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 1862.34 1862.34 aetna hmo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 1862.34 1862.34 aetna pos "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna ppo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna epo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna hmo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna pos "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 1541.69 1541.69 aetna ppo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 1541.69 1541.69 aetna epo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 1541.69 1541.69 aetna hmo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 1541.69 1541.69 aetna pos Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna ppo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna epo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna hmo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 274.98 274.98 aetna pos phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 1541.69 1541.69 aetna ppo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 1541.69 1541.69 aetna epo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 1541.69 1541.69 aetna hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 1541.69 1541.69 aetna pos "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 aetna ppo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 aetna epo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 aetna hmo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 aetna pos X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 aetna ppo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 aetna epo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 aetna hmo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 aetna pos Removal (3 centimeters or greater) tissue growth beneath the skin of pelvis or hip cpt 27043 8313.56 8313.56 8313.56 8313.56 17877.54 17877.54 14897.95 14897.95 O 8313.56 8313.56 aetna ppo Removal (3 centimeters or greater) tissue growth beneath the skin of pelvis or hip cpt 27043 8313.56 8313.56 8313.56 8313.56 17877.54 17877.54 14897.95 14897.95 O 8313.56 8313.56 aetna epo Removal (3 centimeters or greater) tissue growth beneath the skin of pelvis or hip cpt 27043 8313.56 8313.56 8313.56 8313.56 17877.54 17877.54 14897.95 14897.95 O 8313.56 8313.56 aetna hmo Removal (3 centimeters or greater) tissue growth beneath the skin of pelvis or hip cpt 27043 8313.56 8313.56 8313.56 8313.56 17877.54 17877.54 14897.95 14897.95 O 8313.56 8313.56 aetna pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 aetna ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 aetna epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 aetna hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 aetna pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1958.83 1958.83 aetna ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1958.83 1958.83 aetna epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1958.83 1958.83 aetna hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1958.83 1958.83 aetna pos "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3131.05 3131.05 aetna ppo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3131.05 3131.05 aetna epo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3131.05 3131.05 aetna hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3131.05 3131.05 aetna pos X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 264.87 264.87 aetna ppo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 264.87 264.87 aetna epo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 264.87 264.87 aetna hmo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 264.87 264.87 aetna pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.48 8.48 aetna ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.48 8.48 aetna epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.48 8.48 aetna hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.48 8.48 aetna pos "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14120.9 14120.9 aetna ppo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14120.9 14120.9 aetna epo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14120.9 14120.9 aetna hmo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14120.9 14120.9 aetna pos "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 95.08 95.08 aetna ppo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 95.08 95.08 aetna epo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 95.08 95.08 aetna hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 95.08 95.08 aetna pos "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna ppo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna epo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna hmo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 294.34 294.34 aetna ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 294.34 294.34 aetna epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 294.34 294.34 aetna hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 294.34 294.34 aetna pos "aicd, single chamber" cpt C1722 30118.22 30118.22 28054.74 28054.74 104567.21 104567.21 87139.34 87139.34 O 30118.22 30118.22 aetna ppo "aicd, single chamber" cpt C1722 30118.22 30118.22 28054.74 28054.74 104567.21 104567.21 87139.34 87139.34 O 30118.22 30118.22 aetna epo "aicd, single chamber" cpt C1722 30118.22 30118.22 28054.74 28054.74 104567.21 104567.21 87139.34 87139.34 O 30118.22 30118.22 aetna hmo "aicd, single chamber" cpt C1722 30118.22 30118.22 28054.74 28054.74 104567.21 104567.21 87139.34 87139.34 O 30118.22 30118.22 aetna pos "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 14120.9 14120.9 aetna ppo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 14120.9 14120.9 aetna epo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 14120.9 14120.9 aetna hmo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 14120.9 14120.9 aetna pos "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 aetna ppo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 aetna epo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 aetna hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 aetna pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.59 1914.59 aetna ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.59 1914.59 aetna epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.59 1914.59 aetna hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.59 1914.59 aetna pos "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 aetna ppo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 aetna epo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 aetna hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 aetna pos "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1732.38 1732.38 aetna ppo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1732.38 1732.38 aetna epo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1732.38 1732.38 aetna hmo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1732.38 1732.38 aetna pos "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 23772.44 23772.44 aetna ppo "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 23772.44 23772.44 aetna epo "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 23772.44 23772.44 aetna hmo "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 23772.44 23772.44 aetna pos "Ultrasound evaluation of heart blood vessel or graft, each additional vessel" cpt 92979 14120.9 14120.9 172.42 172.42 114856.13 114856.13 95713.44 95713.44 O 14120.9 14120.9 aetna ppo "Ultrasound evaluation of heart blood vessel or graft, each additional vessel" cpt 92979 14120.9 14120.9 172.42 172.42 114856.13 114856.13 95713.44 95713.44 O 14120.9 14120.9 aetna epo "Ultrasound evaluation of heart blood vessel or graft, each additional vessel" cpt 92979 14120.9 14120.9 172.42 172.42 114856.13 114856.13 95713.44 95713.44 O 14120.9 14120.9 aetna hmo "Ultrasound evaluation of heart blood vessel or graft, each additional vessel" cpt 92979 14120.9 14120.9 172.42 172.42 114856.13 114856.13 95713.44 95713.44 O 14120.9 14120.9 aetna pos "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 14120.9 14120.9 aetna ppo "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 14120.9 14120.9 aetna epo "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 14120.9 14120.9 aetna hmo "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 14120.9 14120.9 aetna pos "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 aetna ppo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 aetna epo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 aetna hmo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 aetna pos orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 636.24 636.24 aetna ppo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 636.24 636.24 aetna epo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 636.24 636.24 aetna hmo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 636.24 636.24 aetna pos f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 aetna ppo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 aetna epo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 aetna hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 aetna pos "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 7333.25 7333.25 aetna ppo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 7333.25 7333.25 aetna epo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 7333.25 7333.25 aetna hmo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 7333.25 7333.25 aetna pos acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 5149.04 5149.04 aetna ppo acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 5149.04 5149.04 aetna epo acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 5149.04 5149.04 aetna hmo acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 5149.04 5149.04 aetna pos tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 428.12 428.12 aetna ppo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 428.12 428.12 aetna epo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 428.12 428.12 aetna hmo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 428.12 428.12 aetna pos "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 182.62 182.62 aetna ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 182.62 182.62 aetna epo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 182.62 182.62 aetna hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 182.62 182.62 aetna pos iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 883.06 883.06 aetna ppo iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 883.06 883.06 aetna epo iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 883.06 883.06 aetna hmo iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 883.06 883.06 aetna pos "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 643.93 643.93 aetna ppo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 643.93 643.93 aetna epo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 643.93 643.93 aetna hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 643.93 643.93 aetna pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 260.79 260.79 aetna ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 260.79 260.79 aetna epo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 260.79 260.79 aetna hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 260.79 260.79 aetna pos General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9490.45 9490.45 aetna ppo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9490.45 9490.45 aetna epo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9490.45 9490.45 aetna hmo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9490.45 9490.45 aetna pos "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 14191.44 14191.44 aetna ppo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 14191.44 14191.44 aetna epo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 14191.44 14191.44 aetna hmo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 14191.44 14191.44 aetna pos "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 1971.24 1971.24 aetna ppo "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 1971.24 1971.24 aetna epo "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 1971.24 1971.24 aetna hmo "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 1971.24 1971.24 aetna pos Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1444.99 1444.99 aetna ppo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1444.99 1444.99 aetna epo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1444.99 1444.99 aetna hmo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1444.99 1444.99 aetna pos Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 643.93 643.93 aetna ppo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 643.93 643.93 aetna epo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 643.93 643.93 aetna hmo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 643.93 643.93 aetna pos tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 595.36 595.36 aetna ppo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 595.36 595.36 aetna epo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 595.36 595.36 aetna hmo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 595.36 595.36 aetna pos morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 14120.9 14120.9 aetna ppo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 14120.9 14120.9 aetna epo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 14120.9 14120.9 aetna hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 14120.9 14120.9 aetna pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 aetna ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 aetna epo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 aetna hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 aetna pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 182.62 182.62 aetna ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 182.62 182.62 aetna epo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 182.62 182.62 aetna hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 182.62 182.62 aetna pos "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 167.19 167.19 aetna ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 167.19 167.19 aetna epo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 167.19 167.19 aetna hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 167.19 167.19 aetna pos cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7737.17 7737.17 aetna ppo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7737.17 7737.17 aetna epo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7737.17 7737.17 aetna hmo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7737.17 7737.17 aetna pos tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 aetna ppo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 aetna epo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 aetna hmo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 aetna pos "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 175.74 175.74 aetna ppo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 175.74 175.74 aetna epo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 175.74 175.74 aetna hmo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 175.74 175.74 aetna pos "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 222.64 222.64 aetna ppo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 222.64 222.64 aetna epo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 222.64 222.64 aetna hmo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 222.64 222.64 aetna pos foam drg <=16 sq in w/border cpt A6212 102.66 102.66 102.66 102.66 4253.94 4253.94 3544.95 3544.95 O 102.66 102.66 aetna ppo foam drg <=16 sq in w/border cpt A6212 102.66 102.66 102.66 102.66 4253.94 4253.94 3544.95 3544.95 O 102.66 102.66 aetna epo foam drg <=16 sq in w/border cpt A6212 102.66 102.66 102.66 102.66 4253.94 4253.94 3544.95 3544.95 O 102.66 102.66 aetna hmo foam drg <=16 sq in w/border cpt A6212 102.66 102.66 102.66 102.66 4253.94 4253.94 3544.95 3544.95 O 102.66 102.66 aetna pos alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 64.43 64.43 aetna ppo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 64.43 64.43 aetna epo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 64.43 64.43 aetna hmo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 64.43 64.43 aetna pos "X-ray of chest, minimum of 4 views" cpt 71048 235.15 235.15 22.57 22.57 478.27 478.27 398.56 398.56 O 235.15 235.15 aetna ppo "X-ray of chest, minimum of 4 views" cpt 71048 235.15 235.15 22.57 22.57 478.27 478.27 398.56 398.56 O 235.15 235.15 aetna epo "X-ray of chest, minimum of 4 views" cpt 71048 235.15 235.15 22.57 22.57 478.27 478.27 398.56 398.56 O 235.15 235.15 aetna hmo "X-ray of chest, minimum of 4 views" cpt 71048 235.15 235.15 22.57 22.57 478.27 478.27 398.56 398.56 O 235.15 235.15 aetna pos Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 63.17 63.17 aetna ppo Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 63.17 63.17 aetna epo Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 63.17 63.17 aetna hmo Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 63.17 63.17 aetna pos "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 213.26 213.26 aetna ppo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 213.26 213.26 aetna epo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 213.26 213.26 aetna hmo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 213.26 213.26 aetna pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 aetna ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 aetna epo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 aetna hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 aetna pos morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 1958.83 1958.83 aetna ppo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 1958.83 1958.83 aetna epo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 1958.83 1958.83 aetna hmo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 1958.83 1958.83 aetna pos "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 519.73 519.73 aetna ppo "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 519.73 519.73 aetna epo "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 519.73 519.73 aetna hmo "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 519.73 519.73 aetna pos inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 4294.7 4294.7 aetna ppo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 4294.7 4294.7 aetna epo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 4294.7 4294.7 aetna hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 4294.7 4294.7 aetna pos "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 138.14 138.14 aetna ppo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 138.14 138.14 aetna epo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 138.14 138.14 aetna hmo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 138.14 138.14 aetna pos "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 188.87 188.87 aetna ppo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 188.87 188.87 aetna epo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 188.87 188.87 aetna hmo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 188.87 188.87 aetna pos alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 65.7 65.7 aetna ppo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 65.7 65.7 aetna epo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 65.7 65.7 aetna hmo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 65.7 65.7 aetna pos "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 112.57 112.57 aetna ppo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 112.57 112.57 aetna epo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 112.57 112.57 aetna hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 112.57 112.57 aetna pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 237.89 237.89 aetna ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 237.89 237.89 aetna epo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 237.89 237.89 aetna hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 237.89 237.89 aetna pos Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 1541.11 1541.11 aetna ppo Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 1541.11 1541.11 aetna epo Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 1541.11 1541.11 aetna hmo Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 1541.11 1541.11 aetna pos paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 429.12 429.12 aetna ppo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 429.12 429.12 aetna epo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 429.12 429.12 aetna hmo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 429.12 429.12 aetna pos Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 aetna ppo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 aetna epo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 aetna hmo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 aetna pos meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 1365.87 1365.87 aetna ppo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 1365.87 1365.87 aetna epo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 1365.87 1365.87 aetna hmo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 1365.87 1365.87 aetna pos slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 8300.35 8300.35 aetna ppo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 8300.35 8300.35 aetna epo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 8300.35 8300.35 aetna hmo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 8300.35 8300.35 aetna pos mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 832.09 832.09 aetna ppo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 832.09 832.09 aetna epo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 832.09 832.09 aetna hmo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 832.09 832.09 aetna pos "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 52.53 52.53 aetna ppo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 52.53 52.53 aetna epo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 52.53 52.53 aetna hmo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 52.53 52.53 aetna pos renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 5741.42 5741.42 aetna ppo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 5741.42 5741.42 aetna epo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 5741.42 5741.42 aetna hmo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 5741.42 5741.42 aetna pos Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.16 58.16 aetna ppo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.16 58.16 aetna epo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.16 58.16 aetna hmo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.16 58.16 aetna pos Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 220.77 220.77 aetna ppo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 220.77 220.77 aetna epo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 220.77 220.77 aetna hmo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 220.77 220.77 aetna pos CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 97.4 97.4 aetna ppo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 97.4 97.4 aetna epo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 97.4 97.4 aetna hmo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 97.4 97.4 aetna pos lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 14238.66 14238.66 aetna ppo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 14238.66 14238.66 aetna epo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 14238.66 14238.66 aetna hmo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 14238.66 14238.66 aetna pos Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 163.65 163.65 aetna ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 163.65 163.65 aetna epo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 163.65 163.65 aetna hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 163.65 163.65 aetna pos Removal of fluid from chest cavity with imaging guidance cpt 32555 908.54 908.54 15.04 15.04 4789.2 4789.2 3991 3991 O 908.54 908.54 aetna ppo Removal of fluid from chest cavity with imaging guidance cpt 32555 908.54 908.54 15.04 15.04 4789.2 4789.2 3991 3991 O 908.54 908.54 aetna epo Removal of fluid from chest cavity with imaging guidance cpt 32555 908.54 908.54 15.04 15.04 4789.2 4789.2 3991 3991 O 908.54 908.54 aetna hmo Removal of fluid from chest cavity with imaging guidance cpt 32555 908.54 908.54 15.04 15.04 4789.2 4789.2 3991 3991 O 908.54 908.54 aetna pos "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 44.89 44.89 aetna ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 44.89 44.89 aetna epo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 44.89 44.89 aetna hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 44.89 44.89 aetna pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1423.7 1423.7 aetna ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1423.7 1423.7 aetna epo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1423.7 1423.7 aetna hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1423.7 1423.7 aetna pos CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 799.4 799.4 aetna ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 799.4 799.4 aetna epo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 799.4 799.4 aetna hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 799.4 799.4 aetna pos "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 19.88 19.88 aetna ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 19.88 19.88 aetna epo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 19.88 19.88 aetna hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 19.88 19.88 aetna pos "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 37.84 37.84 aetna ppo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 37.84 37.84 aetna epo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 37.84 37.84 aetna hmo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 37.84 37.84 aetna pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 29.83 29.83 aetna ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 29.83 29.83 aetna epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 29.83 29.83 aetna hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 29.83 29.83 aetna pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 60.66 60.66 aetna ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 60.66 60.66 aetna epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 60.66 60.66 aetna hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 60.66 60.66 aetna pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 62.18 62.18 aetna ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 62.18 62.18 aetna epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 62.18 62.18 aetna hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 62.18 62.18 aetna pos lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 1965.52 1965.52 aetna ppo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 1965.52 1965.52 aetna epo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 1965.52 1965.52 aetna hmo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 1965.52 1965.52 aetna pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 75.61 75.61 aetna ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 75.61 75.61 aetna epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 75.61 75.61 aetna hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 75.61 75.61 aetna pos oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 5479.02 5479.02 aetna ppo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 5479.02 5479.02 aetna epo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 5479.02 5479.02 aetna hmo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 5479.02 5479.02 aetna pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 47.09 47.09 aetna ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 47.09 47.09 aetna epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 47.09 47.09 aetna hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 47.09 47.09 aetna pos methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 10076.53 10076.53 aetna ppo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 10076.53 10076.53 aetna epo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 10076.53 10076.53 aetna hmo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 10076.53 10076.53 aetna pos General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 34.73 34.73 aetna ppo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 34.73 34.73 aetna epo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 34.73 34.73 aetna hmo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 34.73 34.73 aetna pos "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 58.44 58.44 aetna ppo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 58.44 58.44 aetna epo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 58.44 58.44 aetna hmo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 58.44 58.44 aetna pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 130.64 130.64 aetna ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 130.64 130.64 aetna epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 130.64 130.64 aetna hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 130.64 130.64 aetna pos "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1215.96 1215.96 aetna ppo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1215.96 1215.96 aetna epo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1215.96 1215.96 aetna hmo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1215.96 1215.96 aetna pos Ultrasound and monitoring of heart of fetus cpt 76818 456.54 456.54 99.29 99.29 928.56 928.56 773.8 773.8 O 456.54 456.54 aetna ppo Ultrasound and monitoring of heart of fetus cpt 76818 456.54 456.54 99.29 99.29 928.56 928.56 773.8 773.8 O 456.54 456.54 aetna epo Ultrasound and monitoring of heart of fetus cpt 76818 456.54 456.54 99.29 99.29 928.56 928.56 773.8 773.8 O 456.54 456.54 aetna hmo Ultrasound and monitoring of heart of fetus cpt 76818 456.54 456.54 99.29 99.29 928.56 928.56 773.8 773.8 O 456.54 456.54 aetna pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna epo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 175.33 175.33 aetna ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 175.33 175.33 aetna epo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 175.33 175.33 aetna hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 175.33 175.33 aetna pos Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 323.96 323.96 aetna ppo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 323.96 323.96 aetna epo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 323.96 323.96 aetna hmo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 323.96 323.96 aetna pos CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 940.6 940.6 aetna ppo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 940.6 940.6 aetna epo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 940.6 940.6 aetna hmo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 940.6 940.6 aetna pos "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 211.27 211.27 aetna ppo "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 211.27 211.27 aetna epo "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 211.27 211.27 aetna hmo "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 211.27 211.27 aetna pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 63.79 63.79 aetna ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 63.79 63.79 aetna epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 63.79 63.79 aetna hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 63.79 63.79 aetna pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 234.68 234.68 14.94 14.94 274.75 274.75 228.96 228.96 E 139.43 139.43 aetna ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 234.68 234.68 14.94 14.94 274.75 274.75 228.96 228.96 E 139.43 139.43 aetna epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 234.68 234.68 14.94 14.94 274.75 274.75 228.96 228.96 E 139.43 139.43 aetna hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 234.68 234.68 14.94 14.94 274.75 274.75 228.96 228.96 E 139.43 139.43 aetna pos "Detection test by nucleic acid for HIV-1 virus, amplified probe technique" cpt 87535 218.19 218.19 31.21 31.21 429.94 429.94 358.28 358.28 O 218.19 218.19 aetna ppo "Detection test by nucleic acid for HIV-1 virus, amplified probe technique" cpt 87535 218.19 218.19 31.21 31.21 429.94 429.94 358.28 358.28 O 218.19 218.19 aetna epo "Detection test by nucleic acid for HIV-1 virus, amplified probe technique" cpt 87535 218.19 218.19 31.21 31.21 429.94 429.94 358.28 358.28 O 218.19 218.19 aetna hmo "Detection test by nucleic acid for HIV-1 virus, amplified probe technique" cpt 87535 218.19 218.19 31.21 31.21 429.94 429.94 358.28 358.28 O 218.19 218.19 aetna pos levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 1541.69 1541.69 aetna ppo levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 1541.69 1541.69 aetna epo levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 1541.69 1541.69 aetna hmo levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 1541.69 1541.69 aetna pos levofloxacin injection cpt J1956 2485.45 2485.45 941.32 941.32 14500.13 14500.13 12083.44 12083.44 E 1995.04 1995.04 aetna ppo levofloxacin injection cpt J1956 2485.45 2485.45 941.32 941.32 14500.13 14500.13 12083.44 12083.44 E 1995.04 1995.04 aetna epo levofloxacin injection cpt J1956 2485.45 2485.45 941.32 941.32 14500.13 14500.13 12083.44 12083.44 E 1995.04 1995.04 aetna hmo levofloxacin injection cpt J1956 2485.45 2485.45 941.32 941.32 14500.13 14500.13 12083.44 12083.44 E 1995.04 1995.04 aetna pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna pos "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 75.51 75.51 aetna ppo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 75.51 75.51 aetna epo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 75.51 75.51 aetna hmo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 75.51 75.51 aetna pos Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 201.38 201.38 aetna ppo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 201.38 201.38 aetna epo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 201.38 201.38 aetna hmo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 201.38 201.38 aetna pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 7.32 7.32 aetna ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 7.32 7.32 aetna epo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 7.32 7.32 aetna hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 7.32 7.32 aetna pos levetiracetam injection cpt J1953 1444.99 1444.99 943.3 943.3 6504.31 6504.31 5420.26 5420.26 O 1444.99 1444.99 aetna ppo levetiracetam injection cpt J1953 1444.99 1444.99 943.3 943.3 6504.31 6504.31 5420.26 5420.26 O 1444.99 1444.99 aetna epo levetiracetam injection cpt J1953 1444.99 1444.99 943.3 943.3 6504.31 6504.31 5420.26 5420.26 O 1444.99 1444.99 aetna hmo levetiracetam injection cpt J1953 1444.99 1444.99 943.3 943.3 6504.31 6504.31 5420.26 5420.26 O 1444.99 1444.99 aetna pos Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 aetna ppo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 aetna epo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 aetna hmo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 aetna pos furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1855.69 1855.69 aetna ppo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1855.69 1855.69 aetna epo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1855.69 1855.69 aetna hmo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1855.69 1855.69 aetna pos Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 130.4 130.4 aetna ppo Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 130.4 130.4 aetna epo Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 130.4 130.4 aetna hmo Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 130.4 130.4 aetna pos ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 9490.45 9490.45 aetna ppo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 9490.45 9490.45 aetna epo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 9490.45 9490.45 aetna hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 9490.45 9490.45 aetna pos "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 424.02 424.02 aetna ppo "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 424.02 424.02 aetna epo "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 424.02 424.02 aetna hmo "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 424.02 424.02 aetna pos "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 181.37 181.37 aetna ppo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 181.37 181.37 aetna epo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 181.37 181.37 aetna hmo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 181.37 181.37 aetna pos "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 aetna ppo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 aetna epo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 aetna hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 aetna pos "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 228.98 228.98 aetna ppo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 228.98 228.98 aetna epo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 228.98 228.98 aetna hmo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 228.98 228.98 aetna pos Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 aetna ppo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 aetna epo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 aetna hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 aetna pos in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 883.44 883.44 aetna ppo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 883.44 883.44 aetna epo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 883.44 883.44 aetna hmo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 883.44 883.44 aetna pos "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 aetna ppo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 aetna epo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 aetna hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 aetna pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 97.56 97.56 aetna ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 97.56 97.56 aetna epo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 97.56 97.56 aetna hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 97.56 97.56 aetna pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna epo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 78.23 78.23 aetna pos Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.91 8.91 aetna ppo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.91 8.91 aetna epo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.91 8.91 aetna hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.91 8.91 aetna pos ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 640.71 640.71 aetna ppo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 640.71 640.71 aetna epo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 640.71 640.71 aetna hmo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 640.71 640.71 aetna pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 178.68 178.68 aetna ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 178.68 178.68 aetna epo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 178.68 178.68 aetna hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 178.68 178.68 aetna pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 96.59 96.59 aetna ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 96.59 96.59 aetna epo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 96.59 96.59 aetna hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 96.59 96.59 aetna pos Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 23.15 23.15 aetna ppo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 23.15 23.15 aetna epo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 23.15 23.15 aetna hmo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 23.15 23.15 aetna pos "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 143.14 143.14 aetna ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 143.14 143.14 aetna epo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 143.14 143.14 aetna hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 143.14 143.14 aetna pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 57.04 57.04 aetna pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 58.47 58.47 aetna pos Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna ppo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna epo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 59.66 59.66 aetna ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 59.66 59.66 aetna epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 59.66 59.66 aetna hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 59.66 59.66 aetna pos inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1952.13 1952.13 aetna ppo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1952.13 1952.13 aetna epo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1952.13 1952.13 aetna hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1952.13 1952.13 aetna pos Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 84.6 84.6 aetna ppo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 84.6 84.6 aetna epo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 84.6 84.6 aetna hmo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 84.6 84.6 aetna pos Insertion of catheter into urinary duct (ureter) using an endoscope through the bladder area cpt 52005 1569.38 1569.38 1500.24 1500.24 16097.6 16097.6 13414.67 13414.67 O 1541.69 1541.69 aetna ppo Insertion of catheter into urinary duct (ureter) using an endoscope through the bladder area cpt 52005 1569.38 1569.38 1500.24 1500.24 16097.6 16097.6 13414.67 13414.67 O 1541.69 1541.69 aetna epo Insertion of catheter into urinary duct (ureter) using an endoscope through the bladder area cpt 52005 1569.38 1569.38 1500.24 1500.24 16097.6 16097.6 13414.67 13414.67 O 1541.69 1541.69 aetna hmo Insertion of catheter into urinary duct (ureter) using an endoscope through the bladder area cpt 52005 1569.38 1569.38 1500.24 1500.24 16097.6 16097.6 13414.67 13414.67 O 1541.69 1541.69 aetna pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 aetna ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 aetna epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 aetna hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 aetna pos Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 43.82 43.82 aetna ppo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 43.82 43.82 aetna epo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 43.82 43.82 aetna hmo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 43.82 43.82 aetna pos "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 203.3 203.3 aetna ppo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 203.3 203.3 aetna epo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 203.3 203.3 aetna hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 203.3 203.3 aetna pos inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 4307.3 4307.3 aetna ppo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 4307.3 4307.3 aetna epo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 4307.3 4307.3 aetna hmo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 4307.3 4307.3 aetna pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 48.4 48.4 aetna ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 48.4 48.4 aetna epo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 48.4 48.4 aetna hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 48.4 48.4 aetna pos Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna ppo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna epo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 31.83 31.83 aetna pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 152.47 152.47 aetna ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 152.47 152.47 aetna epo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 152.47 152.47 aetna hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 152.47 152.47 aetna pos "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1070.3 1070.3 aetna ppo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1070.3 1070.3 aetna epo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1070.3 1070.3 aetna hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1070.3 1070.3 aetna pos pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 5636.7 5636.7 aetna ppo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 5636.7 5636.7 aetna epo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 5636.7 5636.7 aetna hmo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 5636.7 5636.7 aetna pos "Removal and replacement of defibrillator pulse generator, single wire (lead)" cpt 33262 30118.22 30118.22 30118.22 30118.22 74112.78 74112.78 61760.65 61760.65 O 30118.22 30118.22 aetna ppo "Removal and replacement of defibrillator pulse generator, single wire (lead)" cpt 33262 30118.22 30118.22 30118.22 30118.22 74112.78 74112.78 61760.65 61760.65 O 30118.22 30118.22 aetna epo "Removal and replacement of defibrillator pulse generator, single wire (lead)" cpt 33262 30118.22 30118.22 30118.22 30118.22 74112.78 74112.78 61760.65 61760.65 O 30118.22 30118.22 aetna hmo "Removal and replacement of defibrillator pulse generator, single wire (lead)" cpt 33262 30118.22 30118.22 30118.22 30118.22 74112.78 74112.78 61760.65 61760.65 O 30118.22 30118.22 aetna pos "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 188.87 188.87 aetna ppo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 188.87 188.87 aetna epo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 188.87 188.87 aetna hmo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 188.87 188.87 aetna pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 37.15 37.15 aetna ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 37.15 37.15 aetna epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 37.15 37.15 aetna hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 37.15 37.15 aetna pos Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna ppo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna epo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna hmo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna pos Tissue culture inoculation for virus isolation cpt 87252 80.69 80.69 80.69 80.69 159 159 132.5 132.5 O 80.69 80.69 aetna ppo Tissue culture inoculation for virus isolation cpt 87252 80.69 80.69 80.69 80.69 159 159 132.5 132.5 O 80.69 80.69 aetna epo Tissue culture inoculation for virus isolation cpt 87252 80.69 80.69 80.69 80.69 159 159 132.5 132.5 O 80.69 80.69 aetna hmo Tissue culture inoculation for virus isolation cpt 87252 80.69 80.69 80.69 80.69 159 159 132.5 132.5 O 80.69 80.69 aetna pos "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 133.21 133.21 aetna ppo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 133.21 133.21 aetna epo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 133.21 133.21 aetna hmo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 133.21 133.21 aetna pos Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.52 4.52 aetna ppo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.52 4.52 aetna epo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.52 4.52 aetna hmo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.52 4.52 aetna pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.9 8.9 aetna ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.9 8.9 aetna epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.9 8.9 aetna hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.9 8.9 aetna pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 138.27 138.27 aetna ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 138.27 138.27 aetna epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 138.27 138.27 aetna hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 138.27 138.27 aetna pos "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 362.22 362.22 aetna ppo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 362.22 362.22 aetna epo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 362.22 362.22 aetna hmo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 362.22 362.22 aetna pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 47.15 47.15 aetna ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 47.15 47.15 aetna epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 47.15 47.15 aetna hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 47.15 47.15 aetna pos inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 1952.13 1952.13 aetna ppo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 1952.13 1952.13 aetna epo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 1952.13 1952.13 aetna hmo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 1952.13 1952.13 aetna pos Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna ppo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna epo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna hmo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 65.67 65.67 aetna pos inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 155.75 155.75 aetna ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 155.75 155.75 aetna epo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 155.75 155.75 aetna hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 155.75 155.75 aetna pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.33 5.33 aetna ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.33 5.33 aetna epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.33 5.33 aetna hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.33 5.33 aetna pos Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1089.98 1089.98 aetna ppo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1089.98 1089.98 aetna epo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1089.98 1089.98 aetna hmo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1089.98 1089.98 aetna pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 19.39 19.39 aetna ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 19.39 19.39 aetna epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 19.39 19.39 aetna hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 19.39 19.39 aetna pos "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 205.76 205.76 aetna ppo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 205.76 205.76 aetna epo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 205.76 205.76 aetna hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 205.76 205.76 aetna pos Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.9 8.9 aetna ppo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.9 8.9 aetna epo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.9 8.9 aetna hmo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.9 8.9 aetna pos inj heparin sodium per 10 u cpt J1642 6841.37 6841.37 541.93 541.93 4972.12 4972.12 4143.43 4143.43 E 1753.5 1753.5 aetna ppo inj heparin sodium per 10 u cpt J1642 6841.37 6841.37 541.93 541.93 4972.12 4972.12 4143.43 4143.43 E 1753.5 1753.5 aetna epo inj heparin sodium per 10 u cpt J1642 6841.37 6841.37 541.93 541.93 4972.12 4972.12 4143.43 4143.43 E 1753.5 1753.5 aetna hmo inj heparin sodium per 10 u cpt J1642 6841.37 6841.37 541.93 541.93 4972.12 4972.12 4143.43 4143.43 E 1753.5 1753.5 aetna pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 38.15 38.15 aetna ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 38.15 38.15 aetna epo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 38.15 38.15 aetna hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 38.15 38.15 aetna pos "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 1398.23 1398.23 aetna ppo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 1398.23 1398.23 aetna epo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 1398.23 1398.23 aetna hmo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 1398.23 1398.23 aetna pos Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 aetna ppo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 aetna epo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 aetna hmo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 aetna pos Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2510.82 2510.82 aetna ppo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2510.82 2510.82 aetna epo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2510.82 2510.82 aetna hmo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2510.82 2510.82 aetna pos "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 126.33 126.33 aetna ppo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 126.33 126.33 aetna epo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 126.33 126.33 aetna hmo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 126.33 126.33 aetna pos "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 205.76 205.76 aetna ppo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 205.76 205.76 aetna epo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 205.76 205.76 aetna hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 205.76 205.76 aetna pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.32 8.32 aetna ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.32 8.32 aetna epo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.32 8.32 aetna hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.32 8.32 aetna pos "Crushing, fragmenting, and removal of (less than 2.5 centimeters) bladder stone" cpt 52317 7585.06 7585.06 2652.67 2652.67 15861.14 15861.14 13217.62 13217.62 O 7585.06 7585.06 aetna ppo "Crushing, fragmenting, and removal of (less than 2.5 centimeters) bladder stone" cpt 52317 7585.06 7585.06 2652.67 2652.67 15861.14 15861.14 13217.62 13217.62 O 7585.06 7585.06 aetna epo "Crushing, fragmenting, and removal of (less than 2.5 centimeters) bladder stone" cpt 52317 7585.06 7585.06 2652.67 2652.67 15861.14 15861.14 13217.62 13217.62 O 7585.06 7585.06 aetna hmo "Crushing, fragmenting, and removal of (less than 2.5 centimeters) bladder stone" cpt 52317 7585.06 7585.06 2652.67 2652.67 15861.14 15861.14 13217.62 13217.62 O 7585.06 7585.06 aetna pos Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 28.34 28.34 aetna ppo Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 28.34 28.34 aetna epo Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 28.34 28.34 aetna hmo Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 28.34 28.34 aetna pos "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 10.02 10.02 aetna ppo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 10.02 10.02 aetna epo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 10.02 10.02 aetna hmo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 10.02 10.02 aetna pos fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 6054.77 6054.77 aetna ppo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 6054.77 6054.77 aetna epo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 6054.77 6054.77 aetna hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 6054.77 6054.77 aetna pos Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 2507.56 2507.56 aetna ppo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 2507.56 2507.56 aetna epo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 2507.56 2507.56 aetna hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 2507.56 2507.56 aetna pos "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 10655.83 10655.83 aetna ppo "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 10655.83 10655.83 aetna epo "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 10655.83 10655.83 aetna hmo "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 10655.83 10655.83 aetna pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 327.93 327.93 aetna ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 327.93 327.93 aetna epo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 327.93 327.93 aetna hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 327.93 327.93 aetna pos "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 9.12 9.12 aetna ppo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 9.12 9.12 aetna epo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 9.12 9.12 aetna hmo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 9.12 9.12 aetna pos "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna ppo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna epo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna hmo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna pos Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 111.02 111.02 aetna ppo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 111.02 111.02 aetna epo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 111.02 111.02 aetna hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 111.02 111.02 aetna pos Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1514.71 1514.71 aetna ppo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1514.71 1514.71 aetna epo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1514.71 1514.71 aetna hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1514.71 1514.71 aetna pos X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 445.42 445.42 aetna ppo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 445.42 445.42 aetna epo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 445.42 445.42 aetna hmo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 445.42 445.42 aetna pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 51461.98 51461.98 aetna ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 51461.98 51461.98 aetna epo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 51461.98 51461.98 aetna hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 51461.98 51461.98 aetna pos Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 42.46 42.46 aetna ppo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 42.46 42.46 aetna epo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 42.46 42.46 aetna hmo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 42.46 42.46 aetna pos Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1716.51 1716.51 aetna ppo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1716.51 1716.51 aetna epo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1716.51 1716.51 aetna hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1716.51 1716.51 aetna pos Bacterial blood culture cpt 87040 233.73 233.73 9.18 9.18 280.48 280.48 233.73 233.73 E 132.37 132.37 aetna ppo Bacterial blood culture cpt 87040 233.73 233.73 9.18 9.18 280.48 280.48 233.73 233.73 E 132.37 132.37 aetna epo Bacterial blood culture cpt 87040 233.73 233.73 9.18 9.18 280.48 280.48 233.73 233.73 E 132.37 132.37 aetna hmo Bacterial blood culture cpt 87040 233.73 233.73 9.18 9.18 280.48 280.48 233.73 233.73 E 132.37 132.37 aetna pos Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 293.35 293.35 aetna ppo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 293.35 293.35 aetna epo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 293.35 293.35 aetna hmo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 293.35 293.35 aetna pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2282.87 2282.87 aetna ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2282.87 2282.87 aetna epo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2282.87 2282.87 aetna hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2282.87 2282.87 aetna pos CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna ppo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna epo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna hmo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna pos Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 1995.04 1995.04 aetna ppo Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 1995.04 1995.04 aetna epo Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 1995.04 1995.04 aetna hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 1995.04 1995.04 aetna pos "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 127.12 127.12 aetna ppo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 127.12 127.12 aetna epo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 127.12 127.12 aetna hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 127.12 127.12 aetna pos General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 606.52 606.52 aetna ppo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 606.52 606.52 aetna epo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 606.52 606.52 aetna hmo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 606.52 606.52 aetna pos "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 127.12 127.12 aetna ppo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 127.12 127.12 aetna epo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 127.12 127.12 aetna hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 127.12 127.12 aetna pos Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 46.62 46.62 aetna ppo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 46.62 46.62 aetna epo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 46.62 46.62 aetna hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 46.62 46.62 aetna pos "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 aetna ppo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 aetna epo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 aetna hmo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 aetna pos "Removal of malignant growth (2.1 to 3.0 centimeters) of the face, ears, eyelids, nose, or lips" cpt 11643 1215.96 1215.96 1215.96 1215.96 15226.31 15226.31 12688.59 12688.59 O 1215.96 1215.96 aetna ppo "Removal of malignant growth (2.1 to 3.0 centimeters) of the face, ears, eyelids, nose, or lips" cpt 11643 1215.96 1215.96 1215.96 1215.96 15226.31 15226.31 12688.59 12688.59 O 1215.96 1215.96 aetna epo "Removal of malignant growth (2.1 to 3.0 centimeters) of the face, ears, eyelids, nose, or lips" cpt 11643 1215.96 1215.96 1215.96 1215.96 15226.31 15226.31 12688.59 12688.59 O 1215.96 1215.96 aetna hmo "Removal of malignant growth (2.1 to 3.0 centimeters) of the face, ears, eyelids, nose, or lips" cpt 11643 1215.96 1215.96 1215.96 1215.96 15226.31 15226.31 12688.59 12688.59 O 1215.96 1215.96 aetna pos fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5464.01 5464.01 aetna ppo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5464.01 5464.01 aetna epo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5464.01 5464.01 aetna hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5464.01 5464.01 aetna pos Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 29.61 29.61 aetna ppo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 29.61 29.61 aetna epo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 29.61 29.61 aetna hmo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 29.61 29.61 aetna pos docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 23772.44 23772.44 aetna ppo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 23772.44 23772.44 aetna epo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 23772.44 23772.44 aetna hmo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 23772.44 23772.44 aetna pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 70.26 70.26 aetna ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 70.26 70.26 aetna epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 70.26 70.26 aetna hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 70.26 70.26 aetna pos "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 472.57 472.57 aetna ppo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 472.57 472.57 aetna epo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 472.57 472.57 aetna hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 472.57 472.57 aetna pos "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 732.06 732.06 214.42 214.42 5787.49 5787.49 4822.91 4822.91 E 732.06 732.06 aetna ppo "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 732.06 732.06 214.42 214.42 5787.49 5787.49 4822.91 4822.91 E 732.06 732.06 aetna epo "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 732.06 732.06 214.42 214.42 5787.49 5787.49 4822.91 4822.91 E 732.06 732.06 aetna hmo "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 732.06 732.06 214.42 214.42 5787.49 5787.49 4822.91 4822.91 E 732.06 732.06 aetna pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 96.59 96.59 aetna ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 96.59 96.59 aetna epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 96.59 96.59 aetna hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 96.59 96.59 aetna pos Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1444.99 1444.99 aetna ppo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1444.99 1444.99 aetna epo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1444.99 1444.99 aetna hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1444.99 1444.99 aetna pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 175.74 175.74 aetna ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 175.74 175.74 aetna epo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 175.74 175.74 aetna hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 175.74 175.74 aetna pos inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 987.77 987.77 aetna ppo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 987.77 987.77 aetna epo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 987.77 987.77 aetna hmo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 987.77 987.77 aetna pos "injection, daratumumab 10 mg" cpt J9145 8563.88 8563.88 5143.64 5143.64 15330.14 15330.14 12775.12 12775.12 O 5143.64 5143.64 aetna ppo "injection, daratumumab 10 mg" cpt J9145 8563.88 8563.88 5143.64 5143.64 15330.14 15330.14 12775.12 12775.12 O 5143.64 5143.64 aetna epo "injection, daratumumab 10 mg" cpt J9145 8563.88 8563.88 5143.64 5143.64 15330.14 15330.14 12775.12 12775.12 O 5143.64 5143.64 aetna hmo "injection, daratumumab 10 mg" cpt J9145 8563.88 8563.88 5143.64 5143.64 15330.14 15330.14 12775.12 12775.12 O 5143.64 5143.64 aetna pos Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 51.87 51.87 aetna ppo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 51.87 51.87 aetna epo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 51.87 51.87 aetna hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 51.87 51.87 aetna pos Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 43.82 43.82 aetna ppo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 43.82 43.82 aetna epo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 43.82 43.82 aetna hmo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 43.82 43.82 aetna pos CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna ppo CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna epo CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna hmo CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 876.81 876.81 aetna pos Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 61.97 61.97 aetna ppo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 61.97 61.97 aetna epo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 61.97 61.97 aetna hmo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 61.97 61.97 aetna pos Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 154.28 154.28 aetna ppo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 154.28 154.28 aetna epo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 154.28 154.28 aetna hmo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 154.28 154.28 aetna pos IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 1139.9 1139.9 aetna ppo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 1139.9 1139.9 aetna epo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 1139.9 1139.9 aetna hmo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 1139.9 1139.9 aetna pos psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 2415.43 2415.43 aetna ppo psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 2415.43 2415.43 aetna epo psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 2415.43 2415.43 aetna hmo psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 2415.43 2415.43 aetna pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 401.04 401.04 aetna ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 401.04 401.04 aetna epo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 401.04 401.04 aetna hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 401.04 401.04 aetna pos "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 36.24 36.24 aetna ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 36.24 36.24 aetna epo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 36.24 36.24 aetna hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 36.24 36.24 aetna pos Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 652.29 652.29 aetna ppo Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 652.29 652.29 aetna epo Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 652.29 652.29 aetna hmo Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 652.29 652.29 aetna pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 421.52 421.52 aetna ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 421.52 421.52 aetna epo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 421.52 421.52 aetna hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 421.52 421.52 aetna pos Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 aetna ppo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 aetna epo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 aetna hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 aetna pos Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 29.05 29.05 aetna ppo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 29.05 29.05 aetna epo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 29.05 29.05 aetna hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 29.05 29.05 aetna pos cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 832.09 832.09 aetna ppo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 832.09 832.09 aetna epo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 832.09 832.09 aetna hmo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 832.09 832.09 aetna pos Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 83.27 83.27 aetna ppo Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 83.27 83.27 aetna epo Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 83.27 83.27 aetna hmo Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 83.27 83.27 aetna pos Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1952.13 1952.13 aetna ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1952.13 1952.13 aetna epo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1952.13 1952.13 aetna hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1952.13 1952.13 aetna pos "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 449.64 449.64 aetna ppo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 449.64 449.64 aetna epo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 449.64 449.64 aetna hmo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 449.64 449.64 aetna pos carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 23772.44 23772.44 aetna ppo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 23772.44 23772.44 aetna epo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 23772.44 23772.44 aetna hmo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 23772.44 23772.44 aetna pos "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 319.86 319.86 aetna ppo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 319.86 319.86 aetna epo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 319.86 319.86 aetna hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 319.86 319.86 aetna pos Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 83.27 83.27 aetna ppo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 83.27 83.27 aetna epo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 83.27 83.27 aetna hmo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 83.27 83.27 aetna pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 1103.29 1103.29 aetna ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 1103.29 1103.29 aetna epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 1103.29 1103.29 aetna hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 1103.29 1103.29 aetna pos MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 763.93 763.93 aetna ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 763.93 763.93 aetna epo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 763.93 763.93 aetna hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 763.93 763.93 aetna pos diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 924.13 924.13 aetna ppo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 924.13 924.13 aetna epo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 924.13 924.13 aetna hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 924.13 924.13 aetna pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 1093.21 1093.21 aetna ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 1093.21 1093.21 aetna epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 1093.21 1093.21 aetna hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 1093.21 1093.21 aetna pos Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 27.36 27.36 aetna ppo Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 27.36 27.36 aetna epo Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 27.36 27.36 aetna hmo Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 27.36 27.36 aetna pos Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 58.16 58.16 aetna ppo Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 58.16 58.16 aetna epo Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 58.16 58.16 aetna hmo Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 58.16 58.16 aetna pos Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 51.64 51.64 aetna ppo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 51.64 51.64 aetna epo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 51.64 51.64 aetna hmo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 51.64 51.64 aetna pos MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1548.35 1548.35 aetna ppo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1548.35 1548.35 aetna epo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1548.35 1548.35 aetna hmo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1548.35 1548.35 aetna pos diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1034.56 1034.56 aetna ppo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1034.56 1034.56 aetna epo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1034.56 1034.56 aetna hmo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1034.56 1034.56 aetna pos hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7082.15 7082.15 aetna ppo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7082.15 7082.15 aetna epo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7082.15 7082.15 aetna hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7082.15 7082.15 aetna pos General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1023.76 1023.76 aetna ppo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1023.76 1023.76 aetna epo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1023.76 1023.76 aetna hmo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1023.76 1023.76 aetna pos MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 481.19 481.19 aetna ppo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 481.19 481.19 aetna epo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 481.19 481.19 aetna hmo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 481.19 481.19 aetna pos MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1452.58 1452.58 aetna ppo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1452.58 1452.58 aetna epo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1452.58 1452.58 aetna hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1452.58 1452.58 aetna pos General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1971.24 1971.24 aetna ppo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1971.24 1971.24 aetna epo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1971.24 1971.24 aetna hmo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1971.24 1971.24 aetna pos "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 68.59 68.59 aetna ppo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 68.59 68.59 aetna epo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 68.59 68.59 aetna hmo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 68.59 68.59 aetna pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1284.26 1284.26 aetna ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1284.26 1284.26 aetna epo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1284.26 1284.26 aetna hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1284.26 1284.26 aetna pos "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 48.72 48.72 aetna ppo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 48.72 48.72 aetna epo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 48.72 48.72 aetna hmo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 48.72 48.72 aetna pos hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 2003.41 2003.41 aetna ppo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 2003.41 2003.41 aetna epo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 2003.41 2003.41 aetna hmo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 2003.41 2003.41 aetna pos septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6713.46 6713.46 aetna ppo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6713.46 6713.46 aetna epo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6713.46 6713.46 aetna hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6713.46 6713.46 aetna pos Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 20.87 20.87 aetna ppo Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 20.87 20.87 aetna epo Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 20.87 20.87 aetna hmo Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 20.87 20.87 aetna pos Creation of sling around bladder canal (urethra) to control leakage cpt 57288 9490.45 9490.45 3784.07 3784.07 31149.61 31149.61 25958.01 25958.01 O 9490.45 9490.45 aetna ppo Creation of sling around bladder canal (urethra) to control leakage cpt 57288 9490.45 9490.45 3784.07 3784.07 31149.61 31149.61 25958.01 25958.01 O 9490.45 9490.45 aetna epo Creation of sling around bladder canal (urethra) to control leakage cpt 57288 9490.45 9490.45 3784.07 3784.07 31149.61 31149.61 25958.01 25958.01 O 9490.45 9490.45 aetna hmo Creation of sling around bladder canal (urethra) to control leakage cpt 57288 9490.45 9490.45 3784.07 3784.07 31149.61 31149.61 25958.01 25958.01 O 9490.45 9490.45 aetna pos "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 325.21 325.21 aetna ppo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 325.21 325.21 aetna epo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 325.21 325.21 aetna hmo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 325.21 325.21 aetna pos dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4284.01 4284.01 aetna ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4284.01 4284.01 aetna epo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4284.01 4284.01 aetna hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4284.01 4284.01 aetna pos CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 13.89 13.89 aetna ppo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 13.89 13.89 aetna epo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 13.89 13.89 aetna hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 13.89 13.89 aetna pos bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 5479.02 5479.02 aetna ppo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 5479.02 5479.02 aetna epo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 5479.02 5479.02 aetna hmo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 5479.02 5479.02 aetna pos Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 aetna ppo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 aetna epo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 aetna hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 aetna pos CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1300.21 1300.21 aetna ppo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1300.21 1300.21 aetna epo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1300.21 1300.21 aetna hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1300.21 1300.21 aetna pos post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 7851.31 7851.31 aetna ppo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 7851.31 7851.31 aetna epo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 7851.31 7851.31 aetna hmo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 7851.31 7851.31 aetna pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 27.75 27.75 aetna ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 27.75 27.75 aetna epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 27.75 27.75 aetna hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 27.75 27.75 aetna pos methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 165.81 165.81 aetna ppo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 165.81 165.81 aetna epo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 165.81 165.81 aetna hmo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 165.81 165.81 aetna pos doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 10076.53 10076.53 aetna ppo doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 10076.53 10076.53 aetna epo doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 10076.53 10076.53 aetna hmo doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 10076.53 10076.53 aetna pos Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 21.95 21.95 aetna ppo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 21.95 21.95 aetna epo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 21.95 21.95 aetna hmo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 21.95 21.95 aetna pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 70.04 70.04 aetna ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 70.04 70.04 aetna epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 70.04 70.04 aetna hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 70.04 70.04 aetna pos "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 191.72 191.72 aetna ppo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 191.72 191.72 aetna epo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 191.72 191.72 aetna hmo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 191.72 191.72 aetna pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1705.53 1705.53 aetna ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1705.53 1705.53 aetna epo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1705.53 1705.53 aetna hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1705.53 1705.53 aetna pos "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 4861.41 4861.41 aetna ppo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 4861.41 4861.41 aetna epo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 4861.41 4861.41 aetna hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 4861.41 4861.41 aetna pos lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 87.56 87.56 aetna ppo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 87.56 87.56 aetna epo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 87.56 87.56 aetna hmo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 87.56 87.56 aetna pos MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 aetna ppo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 aetna epo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 aetna hmo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 aetna pos Acute hepatitis panel cpt 80074 224.77 224.77 42.37 42.37 457.15 457.15 380.96 380.96 E 224.77 224.77 aetna ppo Acute hepatitis panel cpt 80074 224.77 224.77 42.37 42.37 457.15 457.15 380.96 380.96 E 224.77 224.77 aetna epo Acute hepatitis panel cpt 80074 224.77 224.77 42.37 42.37 457.15 457.15 380.96 380.96 E 224.77 224.77 aetna hmo Acute hepatitis panel cpt 80074 224.77 224.77 42.37 42.37 457.15 457.15 380.96 380.96 E 224.77 224.77 aetna pos Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1215.96 1215.96 aetna ppo Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1215.96 1215.96 aetna epo Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1215.96 1215.96 aetna hmo Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1215.96 1215.96 aetna pos Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 17.91 17.91 aetna ppo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 17.91 17.91 aetna epo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 17.91 17.91 aetna hmo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 17.91 17.91 aetna pos "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 481 481 aetna ppo "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 481 481 aetna epo "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 481 481 aetna hmo "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 481 481 aetna pos "T cell count and ratio, including ratio" cpt 86360 120.72 120.72 41.79 41.79 237.86 237.86 198.22 198.22 O 120.72 120.72 aetna ppo "T cell count and ratio, including ratio" cpt 86360 120.72 120.72 41.79 41.79 237.86 237.86 198.22 198.22 O 120.72 120.72 aetna epo "T cell count and ratio, including ratio" cpt 86360 120.72 120.72 41.79 41.79 237.86 237.86 198.22 198.22 O 120.72 120.72 aetna hmo "T cell count and ratio, including ratio" cpt 86360 120.72 120.72 41.79 41.79 237.86 237.86 198.22 198.22 O 120.72 120.72 aetna pos "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 aetna ppo "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 aetna epo "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 aetna hmo "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 aetna pos Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 aetna ppo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 aetna epo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 aetna hmo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 aetna pos Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 113.38 113.38 aetna ppo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 113.38 113.38 aetna epo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 113.38 113.38 aetna hmo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 113.38 113.38 aetna pos "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna ppo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna epo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna hmo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 aetna pos prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 1952.13 1952.13 aetna ppo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 1952.13 1952.13 aetna epo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 1952.13 1952.13 aetna hmo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 1952.13 1952.13 aetna pos Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 2442.48 2442.48 aetna ppo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 2442.48 2442.48 aetna epo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 2442.48 2442.48 aetna hmo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 2442.48 2442.48 aetna pos "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 120.08 120.08 aetna ppo "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 120.08 120.08 aetna epo "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 120.08 120.08 aetna hmo "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 120.08 120.08 aetna pos Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5949.32 5949.32 aetna ppo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5949.32 5949.32 aetna epo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5949.32 5949.32 aetna hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5949.32 5949.32 aetna pos prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 1034.56 1034.56 aetna ppo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 1034.56 1034.56 aetna epo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 1034.56 1034.56 aetna hmo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 1034.56 1034.56 aetna pos "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 7851.31 7851.31 aetna ppo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 7851.31 7851.31 aetna epo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 7851.31 7851.31 aetna hmo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 7851.31 7851.31 aetna pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 aetna ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 aetna epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 aetna hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 aetna pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 138.14 138.14 aetna ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 138.14 138.14 aetna epo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 138.14 138.14 aetna hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 138.14 138.14 aetna pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 138.14 138.14 aetna ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 138.14 138.14 aetna epo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 138.14 138.14 aetna hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 138.14 138.14 aetna pos Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 aetna ppo Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 aetna epo Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 aetna hmo Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 aetna pos ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 8253.63 8253.63 aetna ppo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 8253.63 8253.63 aetna epo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 8253.63 8253.63 aetna hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 8253.63 8253.63 aetna pos "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1127.79 1127.79 aetna ppo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1127.79 1127.79 aetna epo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1127.79 1127.79 aetna hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1127.79 1127.79 aetna pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 146.55 146.55 aetna ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 146.55 146.55 aetna epo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 146.55 146.55 aetna hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 146.55 146.55 aetna pos Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 165.81 165.81 aetna ppo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 165.81 165.81 aetna epo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 165.81 165.81 aetna hmo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 165.81 165.81 aetna pos "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 20.41 20.41 aetna ppo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 20.41 20.41 aetna epo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 20.41 20.41 aetna hmo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 20.41 20.41 aetna pos non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 586.4 586.4 aetna ppo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 586.4 586.4 aetna epo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 586.4 586.4 aetna hmo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 586.4 586.4 aetna pos normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 720.46 720.46 aetna ppo normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 720.46 720.46 aetna epo normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 720.46 720.46 aetna hmo normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 720.46 720.46 aetna pos normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 1971.24 1971.24 aetna ppo normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 1971.24 1971.24 aetna epo normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 1971.24 1971.24 aetna hmo normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 1971.24 1971.24 aetna pos Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 20.46 20.46 aetna ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 20.46 20.46 aetna epo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 20.46 20.46 aetna hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 20.46 20.46 aetna pos Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 aetna ppo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 aetna epo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 aetna hmo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 aetna pos ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1995.04 1995.04 aetna ppo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1995.04 1995.04 aetna epo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1995.04 1995.04 aetna hmo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1995.04 1995.04 aetna pos Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 552.04 552.04 aetna ppo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 552.04 552.04 aetna epo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 552.04 552.04 aetna hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 552.04 552.04 aetna pos Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 59.04 59.04 aetna ppo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 59.04 59.04 aetna epo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 59.04 59.04 aetna hmo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 59.04 59.04 aetna pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 293.31 293.31 aetna ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 293.31 293.31 aetna epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 293.31 293.31 aetna hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 293.31 293.31 aetna pos Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 14238.66 14238.66 aetna ppo Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 14238.66 14238.66 aetna epo Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 14238.66 14238.66 aetna hmo Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 14238.66 14238.66 aetna pos "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1444.99 1444.99 aetna ppo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1444.99 1444.99 aetna epo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1444.99 1444.99 aetna hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1444.99 1444.99 aetna pos coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 28603.68 28603.68 aetna ppo coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 28603.68 28603.68 aetna epo coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 28603.68 28603.68 aetna hmo coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 28603.68 28603.68 aetna pos "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 21.89 21.89 aetna ppo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 21.89 21.89 aetna epo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 21.89 21.89 aetna hmo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 21.89 21.89 aetna pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 278.85 278.85 aetna ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 278.85 278.85 aetna epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 278.85 278.85 aetna hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 278.85 278.85 aetna pos cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 8300.35 8300.35 aetna ppo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 8300.35 8300.35 aetna epo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 8300.35 8300.35 aetna hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 8300.35 8300.35 aetna pos normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 2100.38 2100.38 aetna ppo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 2100.38 2100.38 aetna epo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 2100.38 2100.38 aetna hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 2100.38 2100.38 aetna pos leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 6054.77 6054.77 aetna ppo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 6054.77 6054.77 aetna epo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 6054.77 6054.77 aetna hmo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 6054.77 6054.77 aetna pos "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 20.64 20.64 aetna ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 20.64 20.64 aetna epo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 20.64 20.64 aetna hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 20.64 20.64 aetna pos "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1788.91 1788.91 aetna ppo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1788.91 1788.91 aetna epo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1788.91 1788.91 aetna hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1788.91 1788.91 aetna pos "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 164.17 164.17 aetna ppo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 164.17 164.17 aetna epo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 164.17 164.17 aetna hmo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 164.17 164.17 aetna pos other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 5906.23 5906.23 aetna ppo other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 5906.23 5906.23 aetna epo other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 5906.23 5906.23 aetna hmo other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 5906.23 5906.23 aetna pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1952.13 1952.13 aetna ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1952.13 1952.13 aetna epo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1952.13 1952.13 aetna hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1952.13 1952.13 aetna pos Removal of skin and bone cpt 11047 1215.96 1215.96 1196.5 1196.5 8686.8 8686.8 7239 7239 O 1215.96 1215.96 aetna ppo Removal of skin and bone cpt 11047 1215.96 1215.96 1196.5 1196.5 8686.8 8686.8 7239 7239 O 1215.96 1215.96 aetna epo Removal of skin and bone cpt 11047 1215.96 1215.96 1196.5 1196.5 8686.8 8686.8 7239 7239 O 1215.96 1215.96 aetna hmo Removal of skin and bone cpt 11047 1215.96 1215.96 1196.5 1196.5 8686.8 8686.8 7239 7239 O 1215.96 1215.96 aetna pos normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1344.99 1344.99 aetna ppo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1344.99 1344.99 aetna epo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1344.99 1344.99 aetna hmo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1344.99 1344.99 aetna pos "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 474.8 474.8 aetna ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 474.8 474.8 aetna epo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 474.8 474.8 aetna hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 474.8 474.8 aetna pos "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 aetna ppo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 aetna epo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 aetna hmo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 aetna pos CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 639.16 639.16 aetna ppo CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 639.16 639.16 aetna epo CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 639.16 639.16 aetna hmo CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 639.16 639.16 aetna pos "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 347.84 347.84 aetna ppo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 347.84 347.84 aetna epo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 347.84 347.84 aetna hmo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 347.84 347.84 aetna pos atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 14120.9 14120.9 aetna ppo atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 14120.9 14120.9 aetna epo atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 14120.9 14120.9 aetna hmo atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 14120.9 14120.9 aetna pos "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 122.58 122.58 aetna ppo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 122.58 122.58 aetna epo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 122.58 122.58 aetna hmo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 122.58 122.58 aetna pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 9.99 9.99 aetna ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 9.99 9.99 aetna epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 9.99 9.99 aetna hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 9.99 9.99 aetna pos "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 146.34 146.34 aetna ppo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 146.34 146.34 aetna epo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 146.34 146.34 aetna hmo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 146.34 146.34 aetna pos normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 14120.9 14120.9 aetna ppo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 14120.9 14120.9 aetna epo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 14120.9 14120.9 aetna hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 14120.9 14120.9 aetna pos "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 79.71 79.71 aetna ppo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 79.71 79.71 aetna epo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 79.71 79.71 aetna hmo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 79.71 79.71 aetna pos "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 4285.93 4285.93 aetna ppo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 4285.93 4285.93 aetna epo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 4285.93 4285.93 aetna hmo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 4285.93 4285.93 aetna pos azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1995.04 1995.04 aetna ppo azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1995.04 1995.04 aetna epo azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1995.04 1995.04 aetna hmo azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1995.04 1995.04 aetna pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 66.6 66.6 aetna ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 66.6 66.6 aetna epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 66.6 66.6 aetna hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 66.6 66.6 aetna pos "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 174.49 174.49 aetna ppo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 174.49 174.49 aetna epo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 174.49 174.49 aetna hmo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 174.49 174.49 aetna pos "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 112.65 112.65 aetna ppo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 112.65 112.65 aetna epo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 112.65 112.65 aetna hmo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 112.65 112.65 aetna pos hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 11158.76 11158.76 aetna ppo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 11158.76 11158.76 aetna epo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 11158.76 11158.76 aetna hmo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 11158.76 11158.76 aetna pos "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 419.46 419.46 aetna ppo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 419.46 419.46 aetna epo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 419.46 419.46 aetna hmo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 419.46 419.46 aetna pos normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 1927.71 1927.71 aetna ppo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 1927.71 1927.71 aetna epo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 1927.71 1927.71 aetna hmo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 1927.71 1927.71 aetna pos drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 429.12 429.12 aetna ppo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 429.12 429.12 aetna epo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 429.12 429.12 aetna hmo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 429.12 429.12 aetna pos hydralazine hcl injection cpt J0360 2136.63 2136.63 1934.02 1934.02 16012.49 16012.49 13343.74 13343.74 E 1952.13 1952.13 aetna ppo hydralazine hcl injection cpt J0360 2136.63 2136.63 1934.02 1934.02 16012.49 16012.49 13343.74 13343.74 E 1952.13 1952.13 aetna epo hydralazine hcl injection cpt J0360 2136.63 2136.63 1934.02 1934.02 16012.49 16012.49 13343.74 13343.74 E 1952.13 1952.13 aetna hmo hydralazine hcl injection cpt J0360 2136.63 2136.63 1934.02 1934.02 16012.49 16012.49 13343.74 13343.74 E 1952.13 1952.13 aetna pos "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 48.6 48.6 aetna ppo "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 48.6 48.6 aetna epo "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 48.6 48.6 aetna hmo "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 48.6 48.6 aetna pos succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 9113.8 9113.8 aetna ppo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 9113.8 9113.8 aetna epo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 9113.8 9113.8 aetna hmo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 9113.8 9113.8 aetna pos "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 178.85 178.85 aetna ppo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 178.85 178.85 aetna epo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 178.85 178.85 aetna hmo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 178.85 178.85 aetna pos Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 23.1 23.1 aetna ppo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 23.1 23.1 aetna epo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 23.1 23.1 aetna hmo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 23.1 23.1 aetna pos "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 9214.1 9214.1 aetna ppo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 9214.1 9214.1 aetna epo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 9214.1 9214.1 aetna hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 9214.1 9214.1 aetna pos "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 174.49 174.49 aetna ppo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 174.49 174.49 aetna epo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 174.49 174.49 aetna hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 174.49 174.49 aetna pos Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 35.65 35.65 aetna ppo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 35.65 35.65 aetna epo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 35.65 35.65 aetna hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 35.65 35.65 aetna pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 14120.9 14120.9 aetna ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 14120.9 14120.9 aetna epo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 14120.9 14120.9 aetna hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 14120.9 14120.9 aetna pos succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 1218.97 1218.97 aetna ppo succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 1218.97 1218.97 aetna epo succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 1218.97 1218.97 aetna hmo succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 1218.97 1218.97 aetna pos Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 74.62 74.62 aetna ppo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 74.62 74.62 aetna epo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 74.62 74.62 aetna hmo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 74.62 74.62 aetna pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 aetna ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 aetna epo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 aetna hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 aetna pos "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 36.8 36.8 aetna ppo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 36.8 36.8 aetna epo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 36.8 36.8 aetna hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 36.8 36.8 aetna pos inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 376.97 376.97 aetna ppo inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 376.97 376.97 aetna epo inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 376.97 376.97 aetna hmo inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 376.97 376.97 aetna pos cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3849.34 3849.34 aetna ppo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3849.34 3849.34 aetna epo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3849.34 3849.34 aetna hmo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3849.34 3849.34 aetna pos "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 96.83 96.83 aetna ppo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 96.83 96.83 aetna epo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 96.83 96.83 aetna hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 96.83 96.83 aetna pos C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 49.41 49.41 aetna ppo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 49.41 49.41 aetna epo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 49.41 49.41 aetna hmo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 49.41 49.41 aetna pos "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 aetna ppo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 aetna epo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 aetna hmo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 aetna pos Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 1431.27 1431.27 aetna ppo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 1431.27 1431.27 aetna epo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 1431.27 1431.27 aetna hmo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 1431.27 1431.27 aetna pos "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 aetna ppo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 aetna epo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 aetna hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 aetna pos inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 832.09 832.09 aetna ppo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 832.09 832.09 aetna epo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 832.09 832.09 aetna hmo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 832.09 832.09 aetna pos inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 412.37 412.37 aetna ppo inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 412.37 412.37 aetna epo inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 412.37 412.37 aetna hmo inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 412.37 412.37 aetna pos adenosine inj 1mg cpt J0153 9249.37 9249.37 741.72 741.72 36285.3 36285.3 30237.75 30237.75 O 9249.37 9249.37 aetna ppo adenosine inj 1mg cpt J0153 9249.37 9249.37 741.72 741.72 36285.3 36285.3 30237.75 30237.75 O 9249.37 9249.37 aetna epo adenosine inj 1mg cpt J0153 9249.37 9249.37 741.72 741.72 36285.3 36285.3 30237.75 30237.75 O 9249.37 9249.37 aetna hmo adenosine inj 1mg cpt J0153 9249.37 9249.37 741.72 741.72 36285.3 36285.3 30237.75 30237.75 O 9249.37 9249.37 aetna pos "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2073.24 2073.24 aetna ppo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2073.24 2073.24 aetna epo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2073.24 2073.24 aetna hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2073.24 2073.24 aetna pos inj potassium chloride cpt J3480 1971.24 1971.24 725.65 725.65 15041.03 15041.03 12534.19 12534.19 E 1971.24 1971.24 aetna ppo inj potassium chloride cpt J3480 1971.24 1971.24 725.65 725.65 15041.03 15041.03 12534.19 12534.19 E 1971.24 1971.24 aetna epo inj potassium chloride cpt J3480 1971.24 1971.24 725.65 725.65 15041.03 15041.03 12534.19 12534.19 E 1971.24 1971.24 aetna hmo inj potassium chloride cpt J3480 1971.24 1971.24 725.65 725.65 15041.03 15041.03 12534.19 12534.19 E 1971.24 1971.24 aetna pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 26.94 26.94 aetna ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 26.94 26.94 aetna epo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 26.94 26.94 aetna hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 26.94 26.94 aetna pos inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 832.09 832.09 aetna ppo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 832.09 832.09 aetna epo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 832.09 832.09 aetna hmo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 832.09 832.09 aetna pos "injection, inflectra" cpt Q5103 2203.17 2203.17 339.19 339.19 6911.71 6911.71 5759.76 5759.76 O 528.64 528.64 aetna ppo "injection, inflectra" cpt Q5103 2203.17 2203.17 339.19 339.19 6911.71 6911.71 5759.76 5759.76 O 528.64 528.64 aetna epo "injection, inflectra" cpt Q5103 2203.17 2203.17 339.19 339.19 6911.71 6911.71 5759.76 5759.76 O 528.64 528.64 aetna hmo "injection, inflectra" cpt Q5103 2203.17 2203.17 339.19 339.19 6911.71 6911.71 5759.76 5759.76 O 528.64 528.64 aetna pos "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 aetna ppo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 aetna epo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 aetna hmo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 aetna pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2034.14 2034.14 aetna ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2034.14 2034.14 aetna epo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2034.14 2034.14 aetna hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2034.14 2034.14 aetna pos Removal of fibrous nerve growth from between toes cpt 28080 8922.19 8922.19 8922.19 8922.19 16737.58 16737.58 13947.98 13947.98 O 8922.19 8922.19 aetna ppo Removal of fibrous nerve growth from between toes cpt 28080 8922.19 8922.19 8922.19 8922.19 16737.58 16737.58 13947.98 13947.98 O 8922.19 8922.19 aetna epo Removal of fibrous nerve growth from between toes cpt 28080 8922.19 8922.19 8922.19 8922.19 16737.58 16737.58 13947.98 13947.98 O 8922.19 8922.19 aetna hmo Removal of fibrous nerve growth from between toes cpt 28080 8922.19 8922.19 8922.19 8922.19 16737.58 16737.58 13947.98 13947.98 O 8922.19 8922.19 aetna pos "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 95.01 95.01 aetna ppo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 95.01 95.01 aetna epo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 95.01 95.01 aetna hmo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 95.01 95.01 aetna pos Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 aetna ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 aetna epo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 aetna hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 aetna pos "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna ppo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna epo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna hmo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 683.74 683.74 aetna pos "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 3099.83 3099.83 aetna ppo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 3099.83 3099.83 aetna epo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 3099.83 3099.83 aetna hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 3099.83 3099.83 aetna pos "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 57.72 57.72 aetna ppo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 57.72 57.72 aetna epo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 57.72 57.72 aetna hmo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 57.72 57.72 aetna pos acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 9206.32 9206.32 aetna ppo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 9206.32 9206.32 aetna epo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 9206.32 9206.32 aetna hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 9206.32 9206.32 aetna pos acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 875.33 875.33 aetna ppo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 875.33 875.33 aetna epo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 875.33 875.33 aetna hmo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 875.33 875.33 aetna pos "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 aetna ppo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 aetna epo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 aetna hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 aetna pos mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 1336.81 1336.81 aetna ppo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 1336.81 1336.81 aetna epo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 1336.81 1336.81 aetna hmo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 1336.81 1336.81 aetna pos inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 1995.04 1995.04 aetna ppo inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 1995.04 1995.04 aetna epo inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 1995.04 1995.04 aetna hmo inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 1995.04 1995.04 aetna pos Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 36.8 36.8 aetna ppo Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 36.8 36.8 aetna epo Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 36.8 36.8 aetna hmo Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 36.8 36.8 aetna pos Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 aetna ppo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 aetna epo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 aetna hmo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 aetna pos "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 5.02 5.02 aetna ppo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 5.02 5.02 aetna epo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 5.02 5.02 aetna hmo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 5.02 5.02 aetna pos vitamin k phytonadione inj cpt J3430 4902.1 4902.1 1444.99 1444.99 24968.99 24968.99 20807.49 20807.49 O 1444.99 1444.99 aetna ppo vitamin k phytonadione inj cpt J3430 4902.1 4902.1 1444.99 1444.99 24968.99 24968.99 20807.49 20807.49 O 1444.99 1444.99 aetna epo vitamin k phytonadione inj cpt J3430 4902.1 4902.1 1444.99 1444.99 24968.99 24968.99 20807.49 20807.49 O 1444.99 1444.99 aetna hmo vitamin k phytonadione inj cpt J3430 4902.1 4902.1 1444.99 1444.99 24968.99 24968.99 20807.49 20807.49 O 1444.99 1444.99 aetna pos MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1284 1284 aetna ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1284 1284 aetna epo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1284 1284 aetna hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1284 1284 aetna pos "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 213.15 213.15 aetna ppo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 213.15 213.15 aetna epo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 213.15 213.15 aetna hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 213.15 213.15 aetna pos drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 1788.91 1788.91 aetna ppo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 1788.91 1788.91 aetna epo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 1788.91 1788.91 aetna hmo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 1788.91 1788.91 aetna pos "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1705.53 1705.53 aetna ppo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1705.53 1705.53 aetna epo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1705.53 1705.53 aetna hmo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1705.53 1705.53 aetna pos hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 aetna ppo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 aetna epo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 aetna hmo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 aetna pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna epo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 27.89 27.89 aetna pos Insertion of stomach tube using an endoscope cpt 43246 5239.84 5239.84 1368.64 1368.64 4972.94 4972.94 4144.12 4144.12 O 5239.84 5239.84 aetna ppo Insertion of stomach tube using an endoscope cpt 43246 5239.84 5239.84 1368.64 1368.64 4972.94 4972.94 4144.12 4144.12 O 5239.84 5239.84 aetna epo Insertion of stomach tube using an endoscope cpt 43246 5239.84 5239.84 1368.64 1368.64 4972.94 4972.94 4144.12 4144.12 O 5239.84 5239.84 aetna hmo Insertion of stomach tube using an endoscope cpt 43246 5239.84 5239.84 1368.64 1368.64 4972.94 4972.94 4144.12 4144.12 O 5239.84 5239.84 aetna pos "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1596.82 1596.82 aetna ppo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1596.82 1596.82 aetna epo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1596.82 1596.82 aetna hmo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1596.82 1596.82 aetna pos "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 65.71 65.71 aetna ppo "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 65.71 65.71 aetna epo "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 65.71 65.71 aetna hmo "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 65.71 65.71 aetna pos Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 744.67 744.67 aetna ppo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 744.67 744.67 aetna epo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 744.67 744.67 aetna hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 744.67 744.67 aetna pos "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 1969.96 1969.96 aetna ppo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 1969.96 1969.96 aetna epo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 1969.96 1969.96 aetna hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 1969.96 1969.96 aetna pos "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 113.2 113.2 aetna ppo "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 113.2 113.2 aetna epo "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 113.2 113.2 aetna hmo "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 113.2 113.2 aetna pos "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 74.23 74.23 aetna ppo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 74.23 74.23 aetna epo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 74.23 74.23 aetna hmo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 74.23 74.23 aetna pos "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 32.23 32.23 aetna ppo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 32.23 32.23 aetna epo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 32.23 32.23 aetna hmo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 32.23 32.23 aetna pos Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2442.65 2442.65 aetna ppo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2442.65 2442.65 aetna epo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2442.65 2442.65 aetna hmo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2442.65 2442.65 aetna pos "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 3530.58 3530.58 aetna ppo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 3530.58 3530.58 aetna epo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 3530.58 3530.58 aetna hmo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 3530.58 3530.58 aetna pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 97.44 97.44 aetna ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 97.44 97.44 aetna epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 97.44 97.44 aetna hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 97.44 97.44 aetna pos "X-ray of hip with pelvis, minimum of 4 views" cpt 73503 97.4 97.4 97.4 97.4 361.2 361.2 301 301 O 97.4 97.4 aetna ppo "X-ray of hip with pelvis, minimum of 4 views" cpt 73503 97.4 97.4 97.4 97.4 361.2 361.2 301 301 O 97.4 97.4 aetna epo "X-ray of hip with pelvis, minimum of 4 views" cpt 73503 97.4 97.4 97.4 97.4 361.2 361.2 301 301 O 97.4 97.4 aetna hmo "X-ray of hip with pelvis, minimum of 4 views" cpt 73503 97.4 97.4 97.4 97.4 361.2 361.2 301 301 O 97.4 97.4 aetna pos "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 aetna ppo "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 aetna epo "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 aetna hmo "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 aetna pos "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 aetna ppo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 aetna epo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 aetna hmo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 aetna pos Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 53.72 53.72 aetna ppo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 53.72 53.72 aetna epo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 53.72 53.72 aetna hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 53.72 53.72 aetna pos hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1965.52 1965.52 aetna ppo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1965.52 1965.52 aetna epo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1965.52 1965.52 aetna hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1965.52 1965.52 aetna pos rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 606.52 606.52 aetna ppo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 606.52 606.52 aetna epo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 606.52 606.52 aetna hmo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 606.52 606.52 aetna pos "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 26.46 26.46 aetna ppo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 26.46 26.46 aetna epo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 26.46 26.46 aetna hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 26.46 26.46 aetna pos "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 3530.58 3530.58 aetna ppo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 3530.58 3530.58 aetna epo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 3530.58 3530.58 aetna hmo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 3530.58 3530.58 aetna pos "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 aetna ppo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 aetna epo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 aetna hmo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 aetna pos "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.62 5.62 aetna ppo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.62 5.62 aetna epo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.62 5.62 aetna hmo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.62 5.62 aetna pos Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 972.92 972.92 aetna ppo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 972.92 972.92 aetna epo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 972.92 972.92 aetna hmo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 972.92 972.92 aetna pos vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 8866.76 8866.76 aetna ppo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 8866.76 8866.76 aetna epo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 8866.76 8866.76 aetna hmo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 8866.76 8866.76 aetna pos rbc leukoreduced irradiated cpt P9040 1936.52 1936.52 1753.5 1753.5 13153.74 13153.74 10961.45 10961.45 E 1753.5 1753.5 aetna ppo rbc leukoreduced irradiated cpt P9040 1936.52 1936.52 1753.5 1753.5 13153.74 13153.74 10961.45 10961.45 E 1753.5 1753.5 aetna epo rbc leukoreduced irradiated cpt P9040 1936.52 1936.52 1753.5 1753.5 13153.74 13153.74 10961.45 10961.45 E 1753.5 1753.5 aetna hmo rbc leukoreduced irradiated cpt P9040 1936.52 1936.52 1753.5 1753.5 13153.74 13153.74 10961.45 10961.45 E 1753.5 1753.5 aetna pos Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 62.65 62.65 aetna ppo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 62.65 62.65 aetna epo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 62.65 62.65 aetna hmo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 62.65 62.65 aetna pos "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 3530.58 3530.58 aetna ppo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 3530.58 3530.58 aetna epo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 3530.58 3530.58 aetna hmo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 3530.58 3530.58 aetna pos Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 aetna ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 aetna epo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 aetna hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 aetna pos "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 228.51 228.51 aetna ppo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 228.51 228.51 aetna epo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 228.51 228.51 aetna hmo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 228.51 228.51 aetna pos Carboxyhemoglobin (protein) level cpt 82375 98.58 98.58 10.96 10.96 118.3 118.3 98.58 98.58 E 58.16 58.16 aetna ppo Carboxyhemoglobin (protein) level cpt 82375 98.58 98.58 10.96 10.96 118.3 118.3 98.58 98.58 E 58.16 58.16 aetna epo Carboxyhemoglobin (protein) level cpt 82375 98.58 98.58 10.96 10.96 118.3 118.3 98.58 98.58 E 58.16 58.16 aetna hmo Carboxyhemoglobin (protein) level cpt 82375 98.58 98.58 10.96 10.96 118.3 118.3 98.58 98.58 E 58.16 58.16 aetna pos ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70 70 aetna ppo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70 70 aetna epo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70 70 aetna hmo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70 70 aetna pos Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5449 5449 aetna ppo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5449 5449 aetna epo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5449 5449 aetna hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5449 5449 aetna pos Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 6054.77 6054.77 aetna ppo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 6054.77 6054.77 aetna epo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 6054.77 6054.77 aetna hmo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 6054.77 6054.77 aetna pos "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 163.85 163.85 aetna ppo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 163.85 163.85 aetna epo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 163.85 163.85 aetna hmo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 163.85 163.85 aetna pos IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 36.9 36.9 aetna ppo IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 36.9 36.9 aetna epo IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 36.9 36.9 aetna hmo IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 36.9 36.9 aetna pos Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna ppo Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna epo Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna hmo Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna pos triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 347.84 347.84 aetna ppo triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 347.84 347.84 aetna epo triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 347.84 347.84 aetna hmo triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 347.84 347.84 aetna pos Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 5449 5449 aetna ppo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 5449 5449 aetna epo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 5449 5449 aetna hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 5449 5449 aetna pos "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 2668.43 2668.43 aetna ppo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 2668.43 2668.43 aetna epo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 2668.43 2668.43 aetna hmo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 2668.43 2668.43 aetna pos "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 537.22 537.22 aetna ppo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 537.22 537.22 aetna epo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 537.22 537.22 aetna hmo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 537.22 537.22 aetna pos "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 126.52 126.52 aetna ppo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 126.52 126.52 aetna epo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 126.52 126.52 aetna hmo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 126.52 126.52 aetna pos Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna ppo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna epo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna hmo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 39.38 39.38 aetna pos "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 123.94 123.94 aetna ppo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 123.94 123.94 aetna epo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 123.94 123.94 aetna hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 123.94 123.94 aetna pos Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 1052.17 1052.17 aetna ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 1052.17 1052.17 aetna epo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 1052.17 1052.17 aetna hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 1052.17 1052.17 aetna pos Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 aetna ppo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 aetna epo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 aetna hmo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 aetna pos occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 4307.3 4307.3 aetna ppo occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 4307.3 4307.3 aetna epo occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 4307.3 4307.3 aetna hmo occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 4307.3 4307.3 aetna pos Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 6120.94 6120.94 aetna ppo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 6120.94 6120.94 aetna epo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 6120.94 6120.94 aetna hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 6120.94 6120.94 aetna pos Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 9882.2 9882.2 aetna ppo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 9882.2 9882.2 aetna epo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 9882.2 9882.2 aetna hmo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 9882.2 9882.2 aetna pos Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 56.91 56.91 aetna ppo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 56.91 56.91 aetna epo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 56.91 56.91 aetna hmo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 56.91 56.91 aetna pos tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 14156.17 14156.17 aetna ppo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 14156.17 14156.17 aetna epo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 14156.17 14156.17 aetna hmo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 14156.17 14156.17 aetna pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 aetna ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 aetna epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 aetna hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 aetna pos "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 103.19 103.19 aetna ppo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 103.19 103.19 aetna epo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 103.19 103.19 aetna hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 103.19 103.19 aetna pos colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1626.88 1626.88 aetna ppo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1626.88 1626.88 aetna epo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1626.88 1626.88 aetna hmo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1626.88 1626.88 aetna pos Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1493.86 1493.86 aetna ppo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1493.86 1493.86 aetna epo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1493.86 1493.86 aetna hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1493.86 1493.86 aetna pos "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 aetna ppo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 aetna epo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 aetna hmo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 aetna pos rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 720.46 720.46 aetna ppo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 720.46 720.46 aetna epo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 720.46 720.46 aetna hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 720.46 720.46 aetna pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 aetna ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 aetna epo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 aetna hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 aetna pos "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 96.81 96.81 aetna ppo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 96.81 96.81 aetna epo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 96.81 96.81 aetna hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 96.81 96.81 aetna pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 70.09 70.09 aetna ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 70.09 70.09 aetna epo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 70.09 70.09 aetna hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 70.09 70.09 aetna pos Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 7408.69 7408.69 aetna ppo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 7408.69 7408.69 aetna epo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 7408.69 7408.69 aetna hmo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 7408.69 7408.69 aetna pos Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1344.99 1344.99 aetna ppo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1344.99 1344.99 aetna epo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1344.99 1344.99 aetna hmo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1344.99 1344.99 aetna pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 aetna ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 aetna epo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 aetna hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 aetna pos Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 8300.35 8300.35 aetna ppo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 8300.35 8300.35 aetna epo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 8300.35 8300.35 aetna hmo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 8300.35 8300.35 aetna pos fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 7585.06 7585.06 aetna ppo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 7585.06 7585.06 aetna epo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 7585.06 7585.06 aetna hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 7585.06 7585.06 aetna pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1437.97 1437.97 aetna ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1437.97 1437.97 aetna epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1437.97 1437.97 aetna hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1437.97 1437.97 aetna pos Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 27.03 27.03 aetna ppo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 27.03 27.03 aetna epo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 27.03 27.03 aetna hmo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 27.03 27.03 aetna pos Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 69.84 69.84 aetna ppo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 69.84 69.84 aetna epo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 69.84 69.84 aetna hmo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 69.84 69.84 aetna pos "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 125.08 125.08 aetna ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 125.08 125.08 aetna epo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 125.08 125.08 aetna hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 125.08 125.08 aetna pos Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 16.21 16.21 aetna ppo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 16.21 16.21 aetna epo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 16.21 16.21 aetna hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 16.21 16.21 aetna pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 85.88 85.88 aetna ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 85.88 85.88 aetna epo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 85.88 85.88 aetna hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 85.88 85.88 aetna pos Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 aetna ppo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 aetna epo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 aetna hmo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 aetna pos Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 519.73 519.73 aetna ppo Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 519.73 519.73 aetna epo Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 519.73 519.73 aetna hmo Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 519.73 519.73 aetna pos Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 78.23 78.23 aetna ppo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 78.23 78.23 aetna epo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 78.23 78.23 aetna hmo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 78.23 78.23 aetna pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4124.09 4124.09 aetna ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4124.09 4124.09 aetna epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4124.09 4124.09 aetna hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4124.09 4124.09 aetna pos Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 28.3 28.3 aetna ppo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 28.3 28.3 aetna epo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 28.3 28.3 aetna hmo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 28.3 28.3 aetna pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 aetna ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 aetna epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 aetna hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 aetna pos Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 60.04 60.04 aetna ppo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 60.04 60.04 aetna epo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 60.04 60.04 aetna hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 60.04 60.04 aetna pos Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 aetna ppo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 aetna epo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 aetna hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 aetna pos "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 133.84 133.84 aetna ppo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 133.84 133.84 aetna epo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 133.84 133.84 aetna hmo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 133.84 133.84 aetna pos admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 14191.44 14191.44 aetna ppo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 14191.44 14191.44 aetna epo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 14191.44 14191.44 aetna hmo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 14191.44 14191.44 aetna pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 4492.48 4492.48 aetna ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 4492.48 4492.48 aetna epo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 4492.48 4492.48 aetna hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 4492.48 4492.48 aetna pos Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 37.53 37.53 aetna ppo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 37.53 37.53 aetna epo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 37.53 37.53 aetna hmo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 37.53 37.53 aetna pos Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 32.55 32.55 aetna ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 32.55 32.55 aetna epo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 32.55 32.55 aetna hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 32.55 32.55 aetna pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 14238.66 14238.66 aetna ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 14238.66 14238.66 aetna epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 14238.66 14238.66 aetna hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 14238.66 14238.66 aetna pos Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 22.24 22.24 aetna ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 22.24 22.24 aetna epo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 22.24 22.24 aetna hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 22.24 22.24 aetna pos Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 44.65 44.65 aetna ppo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 44.65 44.65 aetna epo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 44.65 44.65 aetna hmo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 44.65 44.65 aetna pos admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 1971.24 1971.24 aetna ppo admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 1971.24 1971.24 aetna epo admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 1971.24 1971.24 aetna hmo admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 1971.24 1971.24 aetna pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 aetna ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 aetna epo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 aetna hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 aetna pos "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna ppo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna epo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna hmo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 174.49 174.49 aetna pos "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 27.2 27.2 aetna ppo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 27.2 27.2 aetna epo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 27.2 27.2 aetna hmo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 27.2 27.2 aetna pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1772.55 1772.55 aetna ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1772.55 1772.55 aetna epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1772.55 1772.55 aetna hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1772.55 1772.55 aetna pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 412.37 412.37 aetna ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 412.37 412.37 aetna epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 412.37 412.37 aetna hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 412.37 412.37 aetna pos fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 669.04 669.04 aetna ppo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 669.04 669.04 aetna epo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 669.04 669.04 aetna hmo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 669.04 669.04 aetna pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 40.65 40.65 aetna ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 40.65 40.65 aetna epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 40.65 40.65 aetna hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 40.65 40.65 aetna pos Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 46.48 46.48 aetna ppo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 46.48 46.48 aetna epo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 46.48 46.48 aetna hmo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 46.48 46.48 aetna pos perc d-e cor stent ather s cpt C9602 14120.9 14120.9 13993.77 13993.77 113173.32 113173.32 94311.1 94311.1 O 14120.9 14120.9 aetna ppo perc d-e cor stent ather s cpt C9602 14120.9 14120.9 13993.77 13993.77 113173.32 113173.32 94311.1 94311.1 O 14120.9 14120.9 aetna epo perc d-e cor stent ather s cpt C9602 14120.9 14120.9 13993.77 13993.77 113173.32 113173.32 94311.1 94311.1 O 14120.9 14120.9 aetna hmo perc d-e cor stent ather s cpt C9602 14120.9 14120.9 13993.77 13993.77 113173.32 113173.32 94311.1 94311.1 O 14120.9 14120.9 aetna pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 aetna ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 aetna epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 aetna hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 aetna pos "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 5988.6 5988.6 aetna ppo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 5988.6 5988.6 aetna epo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 5988.6 5988.6 aetna hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 5988.6 5988.6 aetna pos alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 14238.66 14238.66 aetna ppo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 14238.66 14238.66 aetna epo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 14238.66 14238.66 aetna hmo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 14238.66 14238.66 aetna pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4124.09 4124.09 aetna ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4124.09 4124.09 aetna epo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4124.09 4124.09 aetna hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4124.09 4124.09 aetna pos Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 aetna ppo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 aetna epo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 aetna hmo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 aetna pos perc drug-el cor stent bran cpt C9601 14191.44 14191.44 11308.3 11308.3 114856.13 114856.13 95713.44 95713.44 O 14191.44 14191.44 aetna ppo perc drug-el cor stent bran cpt C9601 14191.44 14191.44 11308.3 11308.3 114856.13 114856.13 95713.44 95713.44 O 14191.44 14191.44 aetna epo perc drug-el cor stent bran cpt C9601 14191.44 14191.44 11308.3 11308.3 114856.13 114856.13 95713.44 95713.44 O 14191.44 14191.44 aetna hmo perc drug-el cor stent bran cpt C9601 14191.44 14191.44 11308.3 11308.3 114856.13 114856.13 95713.44 95713.44 O 14191.44 14191.44 aetna pos "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 56.81 56.81 aetna ppo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 56.81 56.81 aetna epo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 56.81 56.81 aetna hmo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 56.81 56.81 aetna pos rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 936.47 936.47 aetna ppo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 936.47 936.47 aetna epo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 936.47 936.47 aetna hmo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 936.47 936.47 aetna pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11154.03 11154.03 aetna medicare advantage epo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11154.03 11154.03 aetna medicare advantage ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11154.03 11154.03 aetna medicare advantage pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11154.03 11154.03 aetna medicare advantage pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11154.03 11154.03 aetna medicare advantage ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11154.03 11154.03 aetna medicare advantage hmo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 10523.15 10523.15 aetna medicare advantage epo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 10523.15 10523.15 aetna medicare advantage ppo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 10523.15 10523.15 aetna medicare advantage pos respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 10523.15 10523.15 aetna medicare advantage pos respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 10523.15 10523.15 aetna medicare advantage ppo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 10523.15 10523.15 aetna medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 aetna medicare advantage epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 aetna medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 aetna medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 aetna medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 aetna medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 aetna medicare advantage hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 aetna medicare advantage epo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 aetna medicare advantage ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 aetna medicare advantage pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 aetna medicare advantage pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 aetna medicare advantage ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 aetna medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 aetna medicare advantage epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 aetna medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 aetna medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 aetna medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 aetna medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 aetna medicare advantage hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 112.14 112.14 aetna medicare advantage epo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 112.14 112.14 aetna medicare advantage ppo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 112.14 112.14 aetna medicare advantage pos Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 112.14 112.14 aetna medicare advantage pos Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 112.14 112.14 aetna medicare advantage ppo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 112.14 112.14 aetna medicare advantage hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1518.32 1518.32 aetna medicare advantage epo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1518.32 1518.32 aetna medicare advantage ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1518.32 1518.32 aetna medicare advantage pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1518.32 1518.32 aetna medicare advantage pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1518.32 1518.32 aetna medicare advantage ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1518.32 1518.32 aetna medicare advantage hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 42685.48 42685.48 aetna medicare advantage epo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 42685.48 42685.48 aetna medicare advantage ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 42685.48 42685.48 aetna medicare advantage pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 42685.48 42685.48 aetna medicare advantage pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 42685.48 42685.48 aetna medicare advantage ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 42685.48 42685.48 aetna medicare advantage hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 7.45 7.45 aetna medicare advantage epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 7.45 7.45 aetna medicare advantage ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 7.45 7.45 aetna medicare advantage pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 7.45 7.45 aetna medicare advantage pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 7.45 7.45 aetna medicare advantage ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 7.45 7.45 aetna medicare advantage hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage epo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage pos MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage pos MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage epo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage pos MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage pos MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1527.85 1527.85 aetna medicare advantage hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1103.22 1103.22 aetna medicare advantage epo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1103.22 1103.22 aetna medicare advantage ppo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1103.22 1103.22 aetna medicare advantage pos "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1103.22 1103.22 aetna medicare advantage pos "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1103.22 1103.22 aetna medicare advantage ppo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1103.22 1103.22 aetna medicare advantage hmo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6219.34 6219.34 aetna medicare advantage epo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6219.34 6219.34 aetna medicare advantage ppo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6219.34 6219.34 aetna medicare advantage pos renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6219.34 6219.34 aetna medicare advantage pos renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6219.34 6219.34 aetna medicare advantage ppo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6219.34 6219.34 aetna medicare advantage hmo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 21841.06 21841.06 aetna medicare advantage epo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 21841.06 21841.06 aetna medicare advantage ppo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 21841.06 21841.06 aetna medicare advantage pos extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 21841.06 21841.06 aetna medicare advantage pos extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 21841.06 21841.06 aetna medicare advantage ppo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 21841.06 21841.06 aetna medicare advantage hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 aetna medicare advantage epo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 aetna medicare advantage ppo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 aetna medicare advantage pos "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 aetna medicare advantage pos "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 aetna medicare advantage ppo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 aetna medicare advantage hmo skin ulcers with cc ms-drg 593 7479.51 7479.51 3578.19 3578.19 23167.73 23167.73 19306.44 19306.44 I 7479.51 7479.51 aetna medicare advantage epo skin ulcers with cc ms-drg 593 7479.51 7479.51 3578.19 3578.19 23167.73 23167.73 19306.44 19306.44 I 7479.51 7479.51 aetna medicare advantage ppo skin ulcers with cc ms-drg 593 7479.51 7479.51 3578.19 3578.19 23167.73 23167.73 19306.44 19306.44 I 7479.51 7479.51 aetna medicare advantage pos skin ulcers with cc ms-drg 593 7479.51 7479.51 3578.19 3578.19 23167.73 23167.73 19306.44 19306.44 I 7479.51 7479.51 aetna medicare advantage pos skin ulcers with cc ms-drg 593 7479.51 7479.51 3578.19 3578.19 23167.73 23167.73 19306.44 19306.44 I 7479.51 7479.51 aetna medicare advantage ppo skin ulcers with cc ms-drg 593 7479.51 7479.51 3578.19 3578.19 23167.73 23167.73 19306.44 19306.44 I 7479.51 7479.51 aetna medicare advantage hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 68.9 68.9 aetna medicare advantage epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 68.9 68.9 aetna medicare advantage ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 68.9 68.9 aetna medicare advantage pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 68.9 68.9 aetna medicare advantage pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 68.9 68.9 aetna medicare advantage ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 68.9 68.9 aetna medicare advantage hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 12260.28 12260.28 aetna medicare advantage epo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 12260.28 12260.28 aetna medicare advantage ppo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 12260.28 12260.28 aetna medicare advantage pos Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 12260.28 12260.28 aetna medicare advantage pos Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 12260.28 12260.28 aetna medicare advantage ppo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 12260.28 12260.28 aetna medicare advantage hmo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11728.47 11728.47 aetna medicare advantage epo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11728.47 11728.47 aetna medicare advantage ppo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11728.47 11728.47 aetna medicare advantage pos hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11728.47 11728.47 aetna medicare advantage pos hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11728.47 11728.47 aetna medicare advantage ppo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11728.47 11728.47 aetna medicare advantage hmo Removal of one knee cartilage using an endoscope cpt 29881 7460.54 7460.54 2274.34 2274.34 20616.25 20616.25 17180.21 17180.21 O 7460.54 7460.54 bcbs hmo Removal of one knee cartilage using an endoscope cpt 29881 7460.54 7460.54 2274.34 2274.34 20616.25 20616.25 17180.21 17180.21 O 7460.54 7460.54 bcbs hmo Removal of one knee cartilage using an endoscope cpt 29881 7460.54 7460.54 2274.34 2274.34 20616.25 20616.25 17180.21 17180.21 O 7460.54 7460.54 bcbs pos Removal of one knee cartilage using an endoscope cpt 29881 7460.54 7460.54 2274.34 2274.34 20616.25 20616.25 17180.21 17180.21 O 7460.54 7460.54 bcbs ppo Removal of one knee cartilage using an endoscope cpt 29881 7460.54 7460.54 2274.34 2274.34 20616.25 20616.25 17180.21 17180.21 O 7460.54 7460.54 bcbs epo Shaving of shoulder bone using an endoscope cpt 29826 12067.91 12067.91 2425.05 2425.05 31991.54 31991.54 26659.62 26659.62 O 12067.91 12067.91 bcbs hmo Shaving of shoulder bone using an endoscope cpt 29826 12067.91 12067.91 2425.05 2425.05 31991.54 31991.54 26659.62 26659.62 O 12067.91 12067.91 bcbs hmo Shaving of shoulder bone using an endoscope cpt 29826 12067.91 12067.91 2425.05 2425.05 31991.54 31991.54 26659.62 26659.62 O 12067.91 12067.91 bcbs pos Shaving of shoulder bone using an endoscope cpt 29826 12067.91 12067.91 2425.05 2425.05 31991.54 31991.54 26659.62 26659.62 O 12067.91 12067.91 bcbs ppo Shaving of shoulder bone using an endoscope cpt 29826 12067.91 12067.91 2425.05 2425.05 31991.54 31991.54 26659.62 26659.62 O 12067.91 12067.91 bcbs epo "Removal of 1 or more breast growth, open procedure" cpt 19120 3225.81 3225.81 2571.39 2571.39 17570.48 17570.48 14642.07 14642.07 O 3225.81 3225.81 bcbs hmo "Removal of 1 or more breast growth, open procedure" cpt 19120 3225.81 3225.81 2571.39 2571.39 17570.48 17570.48 14642.07 14642.07 O 3225.81 3225.81 bcbs hmo "Removal of 1 or more breast growth, open procedure" cpt 19120 3225.81 3225.81 2571.39 2571.39 17570.48 17570.48 14642.07 14642.07 O 3225.81 3225.81 bcbs pos "Removal of 1 or more breast growth, open procedure" cpt 19120 3225.81 3225.81 2571.39 2571.39 17570.48 17570.48 14642.07 14642.07 O 3225.81 3225.81 bcbs ppo "Removal of 1 or more breast growth, open procedure" cpt 19120 3225.81 3225.81 2571.39 2571.39 17570.48 17570.48 14642.07 14642.07 O 3225.81 3225.81 bcbs epo CT scan of upper spine before and after contrast cpt 72127 350.36 350.36 350.36 350.36 2892.9 2892.9 2410.75 2410.75 O 350.36 350.36 bcbs hmo CT scan of upper spine before and after contrast cpt 72127 350.36 350.36 350.36 350.36 2892.9 2892.9 2410.75 2410.75 O 350.36 350.36 bcbs hmo CT scan of upper spine before and after contrast cpt 72127 350.36 350.36 350.36 350.36 2892.9 2892.9 2410.75 2410.75 O 350.36 350.36 bcbs pos CT scan of upper spine before and after contrast cpt 72127 350.36 350.36 350.36 350.36 2892.9 2892.9 2410.75 2410.75 O 350.36 350.36 bcbs ppo CT scan of upper spine before and after contrast cpt 72127 350.36 350.36 350.36 350.36 2892.9 2892.9 2410.75 2410.75 O 350.36 350.36 bcbs epo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 301.25 301.25 bcbs hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 301.25 301.25 bcbs hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 301.25 301.25 bcbs pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 301.25 301.25 bcbs ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 301.25 301.25 bcbs epo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 208.15 208.15 bcbs hmo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 208.15 208.15 bcbs hmo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 208.15 208.15 bcbs pos Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 208.15 208.15 bcbs ppo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 208.15 208.15 bcbs epo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 575.85 575.85 bcbs hmo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 575.85 575.85 bcbs hmo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 575.85 575.85 bcbs pos CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 575.85 575.85 bcbs ppo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 575.85 575.85 bcbs epo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 197.59 197.59 bcbs hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 197.59 197.59 bcbs hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 197.59 197.59 bcbs pos Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 197.59 197.59 bcbs ppo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 197.59 197.59 bcbs epo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 216.32 216.32 bcbs hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 216.32 216.32 bcbs hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 216.32 216.32 bcbs pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 216.32 216.32 bcbs ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 216.32 216.32 bcbs epo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 229.19 229.19 bcbs hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 229.19 229.19 bcbs hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 229.19 229.19 bcbs pos Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 229.19 229.19 bcbs ppo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 229.19 229.19 bcbs epo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 301.06 301.06 bcbs hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 301.06 301.06 bcbs hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 301.06 301.06 bcbs pos "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 301.06 301.06 bcbs ppo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 301.06 301.06 bcbs epo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 634.34 634.34 bcbs hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 634.34 634.34 bcbs hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 634.34 634.34 bcbs pos MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 634.34 634.34 bcbs ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 634.34 634.34 bcbs epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 781.91 781.91 bcbs hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 781.91 781.91 bcbs hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 781.91 781.91 bcbs pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 781.91 781.91 bcbs ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 781.91 781.91 bcbs epo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs hmo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs hmo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs pos MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs ppo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs epo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs hmo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs hmo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs pos MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs ppo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs epo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 860.61 860.61 bcbs hmo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 860.61 860.61 bcbs hmo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 860.61 860.61 bcbs pos CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 860.61 860.61 bcbs ppo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 860.61 860.61 bcbs epo MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 513.66 513.66 bcbs hmo MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 513.66 513.66 bcbs hmo MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 513.66 513.66 bcbs pos MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 513.66 513.66 bcbs ppo MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 513.66 513.66 bcbs epo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs pos MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs ppo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 458.1 458.1 bcbs epo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 73.01 73.01 bcbs hmo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 73.01 73.01 bcbs hmo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 73.01 73.01 bcbs pos "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 73.01 73.01 bcbs ppo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 73.01 73.01 bcbs epo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 324.93 324.93 bcbs hmo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 324.93 324.93 bcbs hmo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 324.93 324.93 bcbs pos MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 324.93 324.93 bcbs ppo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 324.93 324.93 bcbs epo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 765.83 765.83 bcbs hmo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 765.83 765.83 bcbs hmo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 765.83 765.83 bcbs pos MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 765.83 765.83 bcbs ppo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 765.83 765.83 bcbs epo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 536.32 536.32 bcbs hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 536.32 536.32 bcbs hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 536.32 536.32 bcbs pos CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 536.32 536.32 bcbs ppo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 536.32 536.32 bcbs epo MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 419.53 419.53 bcbs hmo MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 419.53 419.53 bcbs hmo MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 419.53 419.53 bcbs pos MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 419.53 419.53 bcbs ppo MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 419.53 419.53 bcbs epo "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 70.55 70.55 bcbs hmo "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 70.55 70.55 bcbs hmo "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 70.55 70.55 bcbs pos "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 70.55 70.55 bcbs ppo "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 70.55 70.55 bcbs epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 14.68 14.68 bcbs hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 14.68 14.68 bcbs hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 14.68 14.68 bcbs pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 14.68 14.68 bcbs ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 14.68 14.68 bcbs epo CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 559.23 559.23 bcbs hmo CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 559.23 559.23 bcbs hmo CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 559.23 559.23 bcbs pos CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 559.23 559.23 bcbs ppo CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 559.23 559.23 bcbs epo CT scan of pelvis before and after contrast cpt 72194 500.98 500.98 500.98 500.98 2173.01 2173.01 1810.84 1810.84 O 500.98 500.98 bcbs hmo CT scan of pelvis before and after contrast cpt 72194 500.98 500.98 500.98 500.98 2173.01 2173.01 1810.84 1810.84 O 500.98 500.98 bcbs hmo CT scan of pelvis before and after contrast cpt 72194 500.98 500.98 500.98 500.98 2173.01 2173.01 1810.84 1810.84 O 500.98 500.98 bcbs pos CT scan of pelvis before and after contrast cpt 72194 500.98 500.98 500.98 500.98 2173.01 2173.01 1810.84 1810.84 O 500.98 500.98 bcbs ppo CT scan of pelvis before and after contrast cpt 72194 500.98 500.98 500.98 500.98 2173.01 2173.01 1810.84 1810.84 O 500.98 500.98 bcbs epo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1449.9 1449.9 bcbs hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1449.9 1449.9 bcbs hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1449.9 1449.9 bcbs pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1449.9 1449.9 bcbs ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 1449.9 1449.9 bcbs epo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 868.48 868.48 bcbs hmo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 868.48 868.48 bcbs hmo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 868.48 868.48 bcbs pos MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 868.48 868.48 bcbs ppo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 868.48 868.48 bcbs epo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 1644.5 1644.5 bcbs hmo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 1644.5 1644.5 bcbs hmo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 1644.5 1644.5 bcbs pos Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 1644.5 1644.5 bcbs ppo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 1644.5 1644.5 bcbs epo "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 25.28 25.28 bcbs hmo "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 25.28 25.28 bcbs hmo "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 25.28 25.28 bcbs pos "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 25.28 25.28 bcbs ppo "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 25.28 25.28 bcbs epo "X-ray of pelvis, minimum of 2 views" cpt 72220 104.38 104.38 18.36 18.36 244.22 244.22 203.52 203.52 O 104.38 104.38 bcbs hmo "X-ray of pelvis, minimum of 2 views" cpt 72220 104.38 104.38 18.36 18.36 244.22 244.22 203.52 203.52 O 104.38 104.38 bcbs hmo "X-ray of pelvis, minimum of 2 views" cpt 72220 104.38 104.38 18.36 18.36 244.22 244.22 203.52 203.52 O 104.38 104.38 bcbs pos "X-ray of pelvis, minimum of 2 views" cpt 72220 104.38 104.38 18.36 18.36 244.22 244.22 203.52 203.52 O 104.38 104.38 bcbs ppo "X-ray of pelvis, minimum of 2 views" cpt 72220 104.38 104.38 18.36 18.36 244.22 244.22 203.52 203.52 O 104.38 104.38 bcbs epo X-ray of collar bone cpt 73000 70.7 70.7 17.46 17.46 272.21 272.21 226.84 226.84 O 52.19 52.19 bcbs hmo X-ray of collar bone cpt 73000 70.7 70.7 17.46 17.46 272.21 272.21 226.84 226.84 O 52.19 52.19 bcbs hmo X-ray of collar bone cpt 73000 70.7 70.7 17.46 17.46 272.21 272.21 226.84 226.84 O 52.19 52.19 bcbs pos X-ray of collar bone cpt 73000 70.7 70.7 17.46 17.46 272.21 272.21 226.84 226.84 O 52.19 52.19 bcbs ppo X-ray of collar bone cpt 73000 70.7 70.7 17.46 17.46 272.21 272.21 226.84 226.84 O 52.19 52.19 bcbs epo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 3411.24 3411.24 bcbs hmo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 3411.24 3411.24 bcbs hmo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 3411.24 3411.24 bcbs pos "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 3411.24 3411.24 bcbs ppo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 3411.24 3411.24 bcbs epo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1686.21 1686.21 bcbs hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1686.21 1686.21 bcbs hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1686.21 1686.21 bcbs pos "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1686.21 1686.21 bcbs ppo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1686.21 1686.21 bcbs epo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1180.35 1180.35 bcbs hmo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1180.35 1180.35 bcbs hmo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1180.35 1180.35 bcbs pos Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1180.35 1180.35 bcbs ppo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1180.35 1180.35 bcbs epo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 85.38 85.38 bcbs hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 85.38 85.38 bcbs hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 85.38 85.38 bcbs pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 85.38 85.38 bcbs ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 85.38 85.38 bcbs epo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 8816.24 8816.24 bcbs hmo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 8816.24 8816.24 bcbs hmo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 8816.24 8816.24 bcbs pos Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 8816.24 8816.24 bcbs ppo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 8816.24 8816.24 bcbs epo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 380.33 380.33 bcbs hmo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 380.33 380.33 bcbs hmo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 380.33 380.33 bcbs pos Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 380.33 380.33 bcbs ppo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 380.33 380.33 bcbs epo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 7608.35 7608.35 bcbs hmo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 7608.35 7608.35 bcbs hmo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 7608.35 7608.35 bcbs pos Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 7608.35 7608.35 bcbs ppo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 7608.35 7608.35 bcbs epo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 3073.87 3073.87 bcbs hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 3073.87 3073.87 bcbs hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 3073.87 3073.87 bcbs pos "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 3073.87 3073.87 bcbs ppo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 3073.87 3073.87 bcbs epo "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 128.03 128.03 bcbs hmo "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 128.03 128.03 bcbs hmo "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 128.03 128.03 bcbs pos "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 128.03 128.03 bcbs ppo "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 128.03 128.03 bcbs epo "Emergency department visit, problem with significant threat to life or function" cpt 99285 1132.77 1132.77 1132.77 1132.77 7804.86 7804.86 6504.05 6504.05 O 1132.77 1132.77 bcbs hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 1132.77 1132.77 1132.77 1132.77 7804.86 7804.86 6504.05 6504.05 O 1132.77 1132.77 bcbs hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 1132.77 1132.77 1132.77 1132.77 7804.86 7804.86 6504.05 6504.05 O 1132.77 1132.77 bcbs pos "Emergency department visit, problem with significant threat to life or function" cpt 99285 1132.77 1132.77 1132.77 1132.77 7804.86 7804.86 6504.05 6504.05 O 1132.77 1132.77 bcbs ppo "Emergency department visit, problem with significant threat to life or function" cpt 99285 1132.77 1132.77 1132.77 1132.77 7804.86 7804.86 6504.05 6504.05 O 1132.77 1132.77 bcbs epo "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 141.16 141.16 bcbs hmo "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 141.16 141.16 bcbs hmo "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 141.16 141.16 bcbs pos "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 141.16 141.16 bcbs ppo "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 141.16 141.16 bcbs epo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 1405.42 1405.42 bcbs hmo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 1405.42 1405.42 bcbs hmo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 1405.42 1405.42 bcbs pos "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 1405.42 1405.42 bcbs ppo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 1405.42 1405.42 bcbs epo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 600.96 600.96 bcbs hmo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 600.96 600.96 bcbs hmo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 600.96 600.96 bcbs pos "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 600.96 600.96 bcbs ppo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 600.96 600.96 bcbs epo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 178.54 178.54 bcbs hmo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 178.54 178.54 bcbs hmo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 178.54 178.54 bcbs pos "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 178.54 178.54 bcbs ppo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 178.54 178.54 bcbs epo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 487.82 487.82 bcbs hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 487.82 487.82 bcbs hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 487.82 487.82 bcbs pos "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 487.82 487.82 bcbs ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 487.82 487.82 bcbs epo "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 266.68 266.68 bcbs hmo "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 266.68 266.68 bcbs hmo "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 266.68 266.68 bcbs pos "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 266.68 266.68 bcbs ppo "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 266.68 266.68 bcbs epo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 127.09 127.09 bcbs hmo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 127.09 127.09 bcbs hmo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 127.09 127.09 bcbs pos "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 127.09 127.09 bcbs ppo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 127.09 127.09 bcbs epo "Emergency department visit, self limited or minor problem" cpt 99281 183.64 183.64 122.43 122.43 209.88 209.88 174.9 174.9 O 183.64 183.64 bcbs hmo "Emergency department visit, self limited or minor problem" cpt 99281 183.64 183.64 122.43 122.43 209.88 209.88 174.9 174.9 O 183.64 183.64 bcbs hmo "Emergency department visit, self limited or minor problem" cpt 99281 183.64 183.64 122.43 122.43 209.88 209.88 174.9 174.9 O 183.64 183.64 bcbs pos "Emergency department visit, self limited or minor problem" cpt 99281 183.64 183.64 122.43 122.43 209.88 209.88 174.9 174.9 O 183.64 183.64 bcbs ppo "Emergency department visit, self limited or minor problem" cpt 99281 183.64 183.64 122.43 122.43 209.88 209.88 174.9 174.9 O 183.64 183.64 bcbs epo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 353.09 353.09 bcbs hmo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 353.09 353.09 bcbs hmo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 353.09 353.09 bcbs pos "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 353.09 353.09 bcbs ppo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 353.09 353.09 bcbs epo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 249.31 249.31 bcbs hmo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 249.31 249.31 bcbs hmo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 249.31 249.31 bcbs pos "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 249.31 249.31 bcbs ppo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 249.31 249.31 bcbs epo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 66.73 66.73 bcbs hmo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 66.73 66.73 bcbs hmo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 66.73 66.73 bcbs pos "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 66.73 66.73 bcbs ppo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 66.73 66.73 bcbs epo "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 34.96 34.96 bcbs hmo "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 34.96 34.96 bcbs hmo "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 34.96 34.96 bcbs pos "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 34.96 34.96 bcbs ppo "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 34.96 34.96 bcbs epo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 245.53 245.53 bcbs hmo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 245.53 245.53 bcbs hmo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 245.53 245.53 bcbs pos "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 245.53 245.53 bcbs ppo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 245.53 245.53 bcbs epo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 259.15 259.15 bcbs hmo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 259.15 259.15 bcbs hmo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 259.15 259.15 bcbs pos "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 259.15 259.15 bcbs ppo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 259.15 259.15 bcbs epo "New patient office or other outpatient visit, typically 20 minutes" cpt 99202 452.31 452.31 82.86 82.86 1009.96 1009.96 841.63 841.63 O 452.31 452.31 bcbs hmo "New patient office or other outpatient visit, typically 20 minutes" cpt 99202 452.31 452.31 82.86 82.86 1009.96 1009.96 841.63 841.63 O 452.31 452.31 bcbs hmo "New patient office or other outpatient visit, typically 20 minutes" cpt 99202 452.31 452.31 82.86 82.86 1009.96 1009.96 841.63 841.63 O 452.31 452.31 bcbs pos "New patient office or other outpatient visit, typically 20 minutes" cpt 99202 452.31 452.31 82.86 82.86 1009.96 1009.96 841.63 841.63 O 452.31 452.31 bcbs ppo "New patient office or other outpatient visit, typically 20 minutes" cpt 99202 452.31 452.31 82.86 82.86 1009.96 1009.96 841.63 841.63 O 452.31 452.31 bcbs epo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2411.79 2411.79 bcbs hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2411.79 2411.79 bcbs hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2411.79 2411.79 bcbs pos "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2411.79 2411.79 bcbs ppo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2411.79 2411.79 bcbs epo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2411.79 2411.79 bcbs hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2411.79 2411.79 bcbs hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2411.79 2411.79 bcbs pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2411.79 2411.79 bcbs ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2411.79 2411.79 bcbs epo "Negative pressure wound therapy, surface area greater than 50 square centimeters, per session" cpt 97606 556.91 556.91 402.19 402.19 3379.6 3379.6 2816.33 2816.33 O 556.91 556.91 bcbs hmo "Negative pressure wound therapy, surface area greater than 50 square centimeters, per session" cpt 97606 556.91 556.91 402.19 402.19 3379.6 3379.6 2816.33 2816.33 O 556.91 556.91 bcbs hmo "Negative pressure wound therapy, surface area greater than 50 square centimeters, per session" cpt 97606 556.91 556.91 402.19 402.19 3379.6 3379.6 2816.33 2816.33 O 556.91 556.91 bcbs pos "Negative pressure wound therapy, surface area greater than 50 square centimeters, per session" cpt 97606 556.91 556.91 402.19 402.19 3379.6 3379.6 2816.33 2816.33 O 556.91 556.91 bcbs ppo "Negative pressure wound therapy, surface area greater than 50 square centimeters, per session" cpt 97606 556.91 556.91 402.19 402.19 3379.6 3379.6 2816.33 2816.33 O 556.91 556.91 bcbs epo "Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session" cpt 97605 7386.83 7386.83 283.05 283.05 1824.05 1824.05 1520.04 1520.04 O 7386.83 7386.83 bcbs hmo "Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session" cpt 97605 7386.83 7386.83 283.05 283.05 1824.05 1824.05 1520.04 1520.04 O 7386.83 7386.83 bcbs hmo "Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session" cpt 97605 7386.83 7386.83 283.05 283.05 1824.05 1824.05 1520.04 1520.04 O 7386.83 7386.83 bcbs pos "Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session" cpt 97605 7386.83 7386.83 283.05 283.05 1824.05 1824.05 1520.04 1520.04 O 7386.83 7386.83 bcbs ppo "Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session" cpt 97605 7386.83 7386.83 283.05 283.05 1824.05 1824.05 1520.04 1520.04 O 7386.83 7386.83 bcbs epo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 81.13 81.13 bcbs hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 81.13 81.13 bcbs hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 81.13 81.13 bcbs pos "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 81.13 81.13 bcbs ppo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 81.13 81.13 bcbs epo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 964.3 964.3 bcbs hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 964.3 964.3 bcbs hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 964.3 964.3 bcbs pos "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 964.3 964.3 bcbs ppo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 964.3 964.3 bcbs epo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 99.93 99.93 bcbs hmo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 99.93 99.93 bcbs hmo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 99.93 99.93 bcbs pos "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 99.93 99.93 bcbs ppo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 99.93 99.93 bcbs epo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 1023.86 1023.86 bcbs hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 1023.86 1023.86 bcbs hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 1023.86 1023.86 bcbs pos "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 1023.86 1023.86 bcbs ppo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 1023.86 1023.86 bcbs epo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 411.79 411.79 bcbs hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 411.79 411.79 bcbs hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 411.79 411.79 bcbs pos "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 411.79 411.79 bcbs ppo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 411.79 411.79 bcbs epo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 64.2 64.2 bcbs hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 64.2 64.2 bcbs hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 64.2 64.2 bcbs pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 64.2 64.2 bcbs ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 64.2 64.2 bcbs epo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 1195.36 1195.36 bcbs hmo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 1195.36 1195.36 bcbs hmo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 1195.36 1195.36 bcbs pos CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 1195.36 1195.36 bcbs ppo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 1195.36 1195.36 bcbs epo CT scan of arm with contrast cpt 73201 332.86 332.86 272.35 272.35 1507.32 1507.32 1256.1 1256.1 O 272.35 272.35 bcbs hmo CT scan of arm with contrast cpt 73201 332.86 332.86 272.35 272.35 1507.32 1507.32 1256.1 1256.1 O 272.35 272.35 bcbs hmo CT scan of arm with contrast cpt 73201 332.86 332.86 272.35 272.35 1507.32 1507.32 1256.1 1256.1 O 272.35 272.35 bcbs pos CT scan of arm with contrast cpt 73201 332.86 332.86 272.35 272.35 1507.32 1507.32 1256.1 1256.1 O 272.35 272.35 bcbs ppo CT scan of arm with contrast cpt 73201 332.86 332.86 272.35 272.35 1507.32 1507.32 1256.1 1256.1 O 272.35 272.35 bcbs epo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1017.53 1017.53 bcbs hmo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1017.53 1017.53 bcbs hmo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1017.53 1017.53 bcbs pos MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1017.53 1017.53 bcbs ppo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1017.53 1017.53 bcbs epo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 107.4 107.4 bcbs hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 107.4 107.4 bcbs hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 107.4 107.4 bcbs pos "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 107.4 107.4 bcbs ppo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 107.4 107.4 bcbs epo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 167.86 167.86 bcbs hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 167.86 167.86 bcbs hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 167.86 167.86 bcbs pos "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 167.86 167.86 bcbs ppo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 167.86 167.86 bcbs epo MRI scan of arm before and after contrast cpt 73220 1199.98 1199.98 332.86 332.86 3107.5 3107.5 2589.58 2589.58 O 1199.98 1199.98 bcbs hmo MRI scan of arm before and after contrast cpt 73220 1199.98 1199.98 332.86 332.86 3107.5 3107.5 2589.58 2589.58 O 1199.98 1199.98 bcbs hmo MRI scan of arm before and after contrast cpt 73220 1199.98 1199.98 332.86 332.86 3107.5 3107.5 2589.58 2589.58 O 1199.98 1199.98 bcbs pos MRI scan of arm before and after contrast cpt 73220 1199.98 1199.98 332.86 332.86 3107.5 3107.5 2589.58 2589.58 O 1199.98 1199.98 bcbs ppo MRI scan of arm before and after contrast cpt 73220 1199.98 1199.98 332.86 332.86 3107.5 3107.5 2589.58 2589.58 O 1199.98 1199.98 bcbs epo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 3298.14 3298.14 bcbs hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 3298.14 3298.14 bcbs hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 3298.14 3298.14 bcbs pos f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 3298.14 3298.14 bcbs ppo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 3298.14 3298.14 bcbs epo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs pos MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 517.17 517.17 bcbs epo "Self-care or home management training, each 15 minutes" cpt 97535 680.1 680.1 137.83 137.83 2973.6 2973.6 2478 2478 O 400.83 400.83 bcbs hmo "Self-care or home management training, each 15 minutes" cpt 97535 680.1 680.1 137.83 137.83 2973.6 2973.6 2478 2478 O 400.83 400.83 bcbs hmo "Self-care or home management training, each 15 minutes" cpt 97535 680.1 680.1 137.83 137.83 2973.6 2973.6 2478 2478 O 400.83 400.83 bcbs pos "Self-care or home management training, each 15 minutes" cpt 97535 680.1 680.1 137.83 137.83 2973.6 2973.6 2478 2478 O 400.83 400.83 bcbs ppo "Self-care or home management training, each 15 minutes" cpt 97535 680.1 680.1 137.83 137.83 2973.6 2973.6 2478 2478 O 400.83 400.83 bcbs epo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 1177.16 1177.16 bcbs hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 1177.16 1177.16 bcbs hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 1177.16 1177.16 bcbs pos "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 1177.16 1177.16 bcbs ppo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 1177.16 1177.16 bcbs epo MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 891.88 891.88 bcbs hmo MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 891.88 891.88 bcbs hmo MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 891.88 891.88 bcbs pos MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 891.88 891.88 bcbs ppo MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 891.88 891.88 bcbs epo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1692.18 1692.18 bcbs hmo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1692.18 1692.18 bcbs hmo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1692.18 1692.18 bcbs pos "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1692.18 1692.18 bcbs ppo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 1692.18 1692.18 bcbs epo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1260.46 1260.46 bcbs hmo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1260.46 1260.46 bcbs hmo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1260.46 1260.46 bcbs pos "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1260.46 1260.46 bcbs ppo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 1260.46 1260.46 bcbs epo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 61.44 61.44 bcbs hmo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 61.44 61.44 bcbs hmo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 61.44 61.44 bcbs pos "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 61.44 61.44 bcbs ppo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 61.44 61.44 bcbs epo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3531.48 3531.48 bcbs hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3531.48 3531.48 bcbs hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3531.48 3531.48 bcbs pos "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3531.48 3531.48 bcbs ppo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3531.48 3531.48 bcbs epo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 882.87 882.87 bcbs hmo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 882.87 882.87 bcbs hmo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 882.87 882.87 bcbs pos "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 882.87 882.87 bcbs ppo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 882.87 882.87 bcbs epo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 2046.31 2046.31 bcbs hmo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 2046.31 2046.31 bcbs hmo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 2046.31 2046.31 bcbs pos "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 2046.31 2046.31 bcbs ppo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 2046.31 2046.31 bcbs epo "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 102.22 102.22 bcbs hmo "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 102.22 102.22 bcbs hmo "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 102.22 102.22 bcbs pos "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 102.22 102.22 bcbs ppo "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 102.22 102.22 bcbs epo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 1047.49 1047.49 bcbs hmo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 1047.49 1047.49 bcbs hmo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 1047.49 1047.49 bcbs pos "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 1047.49 1047.49 bcbs ppo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 1047.49 1047.49 bcbs epo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 1181.4 1181.4 bcbs hmo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 1181.4 1181.4 bcbs hmo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 1181.4 1181.4 bcbs pos Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 1181.4 1181.4 bcbs ppo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 1181.4 1181.4 bcbs epo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs pos Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs epo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 117.36 117.36 bcbs hmo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 117.36 117.36 bcbs hmo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 117.36 117.36 bcbs pos "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 117.36 117.36 bcbs ppo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 117.36 117.36 bcbs epo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 8152.79 8152.79 bcbs hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 8152.79 8152.79 bcbs hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 8152.79 8152.79 bcbs pos Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 8152.79 8152.79 bcbs ppo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 8152.79 8152.79 bcbs epo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 97.85 97.85 bcbs hmo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 97.85 97.85 bcbs hmo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 97.85 97.85 bcbs pos "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 97.85 97.85 bcbs ppo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 97.85 97.85 bcbs epo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 5901.94 5901.94 bcbs hmo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 5901.94 5901.94 bcbs hmo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 5901.94 5901.94 bcbs pos Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 5901.94 5901.94 bcbs ppo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 5901.94 5901.94 bcbs epo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 1629.98 1629.98 bcbs hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 1629.98 1629.98 bcbs hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 1629.98 1629.98 bcbs pos Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 1629.98 1629.98 bcbs ppo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 1629.98 1629.98 bcbs epo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 3867.45 3867.45 bcbs hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 3867.45 3867.45 bcbs hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 3867.45 3867.45 bcbs pos Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 3867.45 3867.45 bcbs ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 3867.45 3867.45 bcbs epo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 61.44 61.44 bcbs hmo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 61.44 61.44 bcbs hmo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 61.44 61.44 bcbs pos "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 61.44 61.44 bcbs ppo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 61.44 61.44 bcbs epo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 7924.91 7924.91 bcbs hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 7924.91 7924.91 bcbs hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 7924.91 7924.91 bcbs pos Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 7924.91 7924.91 bcbs ppo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 7924.91 7924.91 bcbs epo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 5117.27 5117.27 bcbs hmo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 5117.27 5117.27 bcbs hmo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 5117.27 5117.27 bcbs pos slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 5117.27 5117.27 bcbs ppo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 5117.27 5117.27 bcbs epo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 2537.15 2537.15 bcbs hmo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 2537.15 2537.15 bcbs hmo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 2537.15 2537.15 bcbs pos Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 2537.15 2537.15 bcbs ppo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 2537.15 2537.15 bcbs epo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2435.76 2435.76 bcbs hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2435.76 2435.76 bcbs hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2435.76 2435.76 bcbs pos Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2435.76 2435.76 bcbs ppo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2435.76 2435.76 bcbs epo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 61.44 61.44 bcbs hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 61.44 61.44 bcbs hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 61.44 61.44 bcbs pos "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 61.44 61.44 bcbs ppo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 61.44 61.44 bcbs epo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 4264.13 4264.13 bcbs hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 4264.13 4264.13 bcbs hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 4264.13 4264.13 bcbs pos Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 4264.13 4264.13 bcbs ppo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 4264.13 4264.13 bcbs epo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 13222.87 13222.87 bcbs hmo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 13222.87 13222.87 bcbs hmo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 13222.87 13222.87 bcbs pos Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 13222.87 13222.87 bcbs ppo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 13222.87 13222.87 bcbs epo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 102.67 102.67 bcbs hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 102.67 102.67 bcbs hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 102.67 102.67 bcbs pos "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 102.67 102.67 bcbs ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 102.67 102.67 bcbs epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 1647.76 1647.76 bcbs hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 1647.76 1647.76 bcbs hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 1647.76 1647.76 bcbs pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 1647.76 1647.76 bcbs ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 1647.76 1647.76 bcbs epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 1781.26 1781.26 bcbs hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 1781.26 1781.26 bcbs hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 1781.26 1781.26 bcbs pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 1781.26 1781.26 bcbs ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 1781.26 1781.26 bcbs epo "X-ray of both knees, standing, front to back view" cpt 73565 61.44 61.44 24.61 24.61 363.79 363.79 303.16 303.16 O 61.44 61.44 bcbs hmo "X-ray of both knees, standing, front to back view" cpt 73565 61.44 61.44 24.61 24.61 363.79 363.79 303.16 303.16 O 61.44 61.44 bcbs hmo "X-ray of both knees, standing, front to back view" cpt 73565 61.44 61.44 24.61 24.61 363.79 363.79 303.16 303.16 O 61.44 61.44 bcbs pos "X-ray of both knees, standing, front to back view" cpt 73565 61.44 61.44 24.61 24.61 363.79 363.79 303.16 303.16 O 61.44 61.44 bcbs ppo "X-ray of both knees, standing, front to back view" cpt 73565 61.44 61.44 24.61 24.61 363.79 363.79 303.16 303.16 O 61.44 61.44 bcbs epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1440.1 1440.1 bcbs hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1440.1 1440.1 bcbs hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1440.1 1440.1 bcbs pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1440.1 1440.1 bcbs ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1440.1 1440.1 bcbs epo "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 197.67 197.67 bcbs hmo "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 197.67 197.67 bcbs hmo "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 197.67 197.67 bcbs pos "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 197.67 197.67 bcbs ppo "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 197.67 197.67 bcbs epo "X-ray of ankle, 2 views" cpt 73600 70.7 70.7 19.45 19.45 272.21 272.21 226.84 226.84 O 46.08 46.08 bcbs hmo "X-ray of ankle, 2 views" cpt 73600 70.7 70.7 19.45 19.45 272.21 272.21 226.84 226.84 O 46.08 46.08 bcbs hmo "X-ray of ankle, 2 views" cpt 73600 70.7 70.7 19.45 19.45 272.21 272.21 226.84 226.84 O 46.08 46.08 bcbs pos "X-ray of ankle, 2 views" cpt 73600 70.7 70.7 19.45 19.45 272.21 272.21 226.84 226.84 O 46.08 46.08 bcbs ppo "X-ray of ankle, 2 views" cpt 73600 70.7 70.7 19.45 19.45 272.21 272.21 226.84 226.84 O 46.08 46.08 bcbs epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 659.59 659.59 bcbs hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 659.59 659.59 bcbs hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 659.59 659.59 bcbs pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 659.59 659.59 bcbs ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 659.59 659.59 bcbs epo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 98.4 98.4 bcbs hmo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 98.4 98.4 bcbs hmo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 98.4 98.4 bcbs pos "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 98.4 98.4 bcbs ppo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 98.4 98.4 bcbs epo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 2009.92 2009.92 bcbs hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 2009.92 2009.92 bcbs hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 2009.92 2009.92 bcbs pos "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 2009.92 2009.92 bcbs ppo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 2009.92 2009.92 bcbs epo "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 41.17 41.17 bcbs hmo "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 41.17 41.17 bcbs hmo "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 41.17 41.17 bcbs pos "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 41.17 41.17 bcbs ppo "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 41.17 41.17 bcbs epo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 1366.77 1366.77 bcbs hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 1366.77 1366.77 bcbs hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 1366.77 1366.77 bcbs pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 1366.77 1366.77 bcbs ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 1366.77 1366.77 bcbs epo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 588.86 588.86 bcbs hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 588.86 588.86 bcbs hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 588.86 588.86 bcbs pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 588.86 588.86 bcbs ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 588.86 588.86 bcbs epo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 61.44 61.44 bcbs hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 61.44 61.44 bcbs hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 61.44 61.44 bcbs pos "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 61.44 61.44 bcbs ppo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 61.44 61.44 bcbs epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 1077.64 1077.64 bcbs hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 1077.64 1077.64 bcbs hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 1077.64 1077.64 bcbs pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 1077.64 1077.64 bcbs ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 1077.64 1077.64 bcbs epo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 1106.07 1106.07 bcbs hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 1106.07 1106.07 bcbs hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 1106.07 1106.07 bcbs pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 1106.07 1106.07 bcbs ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 1106.07 1106.07 bcbs epo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 61.44 61.44 bcbs hmo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 61.44 61.44 bcbs hmo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 61.44 61.44 bcbs pos "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 61.44 61.44 bcbs ppo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 61.44 61.44 bcbs epo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 1179.83 1179.83 bcbs hmo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 1179.83 1179.83 bcbs hmo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 1179.83 1179.83 bcbs pos "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 1179.83 1179.83 bcbs ppo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 1179.83 1179.83 bcbs epo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 60.64 60.64 bcbs hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 60.64 60.64 bcbs hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 60.64 60.64 bcbs pos "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 60.64 60.64 bcbs ppo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 60.64 60.64 bcbs epo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1644.5 1644.5 bcbs hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1644.5 1644.5 bcbs hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1644.5 1644.5 bcbs pos Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1644.5 1644.5 bcbs ppo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1644.5 1644.5 bcbs epo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 482.16 482.16 bcbs hmo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 482.16 482.16 bcbs hmo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 482.16 482.16 bcbs pos CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 482.16 482.16 bcbs ppo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 482.16 482.16 bcbs epo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 1581.95 1581.95 bcbs hmo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 1581.95 1581.95 bcbs hmo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 1581.95 1581.95 bcbs pos Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 1581.95 1581.95 bcbs ppo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 1581.95 1581.95 bcbs epo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs pos Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs ppo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs epo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 919.58 919.58 bcbs hmo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 919.58 919.58 bcbs hmo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 919.58 919.58 bcbs pos MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 919.58 919.58 bcbs ppo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 919.58 919.58 bcbs epo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 678.84 678.84 bcbs hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 678.84 678.84 bcbs hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 678.84 678.84 bcbs pos Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 678.84 678.84 bcbs ppo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 678.84 678.84 bcbs epo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 762.39 762.39 bcbs hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 762.39 762.39 bcbs hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 762.39 762.39 bcbs pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 762.39 762.39 bcbs ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 762.39 762.39 bcbs epo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 294.32 294.32 bcbs hmo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 294.32 294.32 bcbs hmo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 294.32 294.32 bcbs pos "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 294.32 294.32 bcbs ppo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 294.32 294.32 bcbs epo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 82.35 82.35 bcbs hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 82.35 82.35 bcbs hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 82.35 82.35 bcbs pos "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 82.35 82.35 bcbs ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 82.35 82.35 bcbs epo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 273.8 273.8 bcbs hmo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 273.8 273.8 bcbs hmo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 273.8 273.8 bcbs pos Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 273.8 273.8 bcbs ppo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 273.8 273.8 bcbs epo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs pos Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs epo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 464.59 464.59 bcbs hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 464.59 464.59 bcbs hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 464.59 464.59 bcbs pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 464.59 464.59 bcbs ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 464.59 464.59 bcbs epo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 61.44 61.44 bcbs hmo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 61.44 61.44 bcbs hmo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 61.44 61.44 bcbs pos "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 61.44 61.44 bcbs ppo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 61.44 61.44 bcbs epo Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 282.79 282.79 bcbs hmo Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 282.79 282.79 bcbs hmo Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 282.79 282.79 bcbs pos Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 282.79 282.79 bcbs ppo Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 282.79 282.79 bcbs epo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 359.62 359.62 bcbs hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 359.62 359.62 bcbs hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 359.62 359.62 bcbs pos Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 359.62 359.62 bcbs ppo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 359.62 359.62 bcbs epo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 37.21 37.21 bcbs hmo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 37.21 37.21 bcbs hmo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 37.21 37.21 bcbs pos Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 37.21 37.21 bcbs ppo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 37.21 37.21 bcbs epo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs hmo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs hmo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs pos Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs ppo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 359.62 359.62 bcbs epo CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 592.16 592.16 bcbs hmo CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 592.16 592.16 bcbs hmo CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 592.16 592.16 bcbs pos CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 592.16 592.16 bcbs ppo CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 592.16 592.16 bcbs epo "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 286.66 286.66 bcbs hmo "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 286.66 286.66 bcbs hmo "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 286.66 286.66 bcbs pos "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 286.66 286.66 bcbs ppo "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 286.66 286.66 bcbs epo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 502.02 502.02 bcbs hmo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 502.02 502.02 bcbs hmo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 502.02 502.02 bcbs pos CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 502.02 502.02 bcbs ppo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 502.02 502.02 bcbs epo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 216.32 216.32 bcbs hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 216.32 216.32 bcbs hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 216.32 216.32 bcbs pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 216.32 216.32 bcbs ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 216.32 216.32 bcbs epo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 861.28 861.28 bcbs hmo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 861.28 861.28 bcbs hmo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 861.28 861.28 bcbs pos Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 861.28 861.28 bcbs ppo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 861.28 861.28 bcbs epo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 2071.58 2071.58 bcbs hmo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 2071.58 2071.58 bcbs hmo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 2071.58 2071.58 bcbs pos CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 2071.58 2071.58 bcbs ppo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 2071.58 2071.58 bcbs epo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 632.1 632.1 bcbs hmo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 632.1 632.1 bcbs hmo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 632.1 632.1 bcbs pos CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 632.1 632.1 bcbs ppo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 632.1 632.1 bcbs epo Peripheral arterial disease (PAD) rehabilitation per session cpt 93668 882.84 882.84 389.84 389.84 1271.42 1271.42 1059.52 1059.52 O 882.84 882.84 bcbs hmo Peripheral arterial disease (PAD) rehabilitation per session cpt 93668 882.84 882.84 389.84 389.84 1271.42 1271.42 1059.52 1059.52 O 882.84 882.84 bcbs hmo Peripheral arterial disease (PAD) rehabilitation per session cpt 93668 882.84 882.84 389.84 389.84 1271.42 1271.42 1059.52 1059.52 O 882.84 882.84 bcbs pos Peripheral arterial disease (PAD) rehabilitation per session cpt 93668 882.84 882.84 389.84 389.84 1271.42 1271.42 1059.52 1059.52 O 882.84 882.84 bcbs ppo Peripheral arterial disease (PAD) rehabilitation per session cpt 93668 882.84 882.84 389.84 389.84 1271.42 1271.42 1059.52 1059.52 O 882.84 882.84 bcbs epo Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 286.66 286.66 bcbs hmo Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 286.66 286.66 bcbs hmo Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 286.66 286.66 bcbs pos Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 286.66 286.66 bcbs ppo Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 286.66 286.66 bcbs epo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2405.95 2405.95 bcbs hmo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2405.95 2405.95 bcbs hmo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2405.95 2405.95 bcbs pos Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2405.95 2405.95 bcbs ppo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2405.95 2405.95 bcbs epo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 968.88 968.88 bcbs hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 968.88 968.88 bcbs hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 968.88 968.88 bcbs pos CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 968.88 968.88 bcbs ppo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 968.88 968.88 bcbs epo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 8256.27 8256.27 bcbs hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 8256.27 8256.27 bcbs hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 8256.27 8256.27 bcbs pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 8256.27 8256.27 bcbs ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 8256.27 8256.27 bcbs epo "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 514.25 514.25 bcbs hmo "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 514.25 514.25 bcbs hmo "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 514.25 514.25 bcbs pos "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 514.25 514.25 bcbs ppo "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 514.25 514.25 bcbs epo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 1612.53 1612.53 bcbs hmo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 1612.53 1612.53 bcbs hmo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 1612.53 1612.53 bcbs pos Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 1612.53 1612.53 bcbs ppo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 1612.53 1612.53 bcbs epo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 1825.81 1825.81 bcbs hmo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 1825.81 1825.81 bcbs hmo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 1825.81 1825.81 bcbs pos CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 1825.81 1825.81 bcbs ppo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 1825.81 1825.81 bcbs epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 514.25 514.25 bcbs hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 514.25 514.25 bcbs hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 514.25 514.25 bcbs pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 514.25 514.25 bcbs ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 514.25 514.25 bcbs epo "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 76.59 76.59 bcbs hmo "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 76.59 76.59 bcbs hmo "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 76.59 76.59 bcbs pos "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 76.59 76.59 bcbs ppo "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 76.59 76.59 bcbs epo MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 2589.58 2589.58 bcbs hmo MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 2589.58 2589.58 bcbs hmo MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 2589.58 2589.58 bcbs pos MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 2589.58 2589.58 bcbs ppo MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 2589.58 2589.58 bcbs epo "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 71.59 71.59 bcbs hmo "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 71.59 71.59 bcbs hmo "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 71.59 71.59 bcbs pos "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 71.59 71.59 bcbs ppo "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 71.59 71.59 bcbs epo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 124.38 124.38 bcbs hmo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 124.38 124.38 bcbs hmo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 124.38 124.38 bcbs pos Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 124.38 124.38 bcbs ppo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 124.38 124.38 bcbs epo X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 117.12 117.12 bcbs hmo X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 117.12 117.12 bcbs hmo X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 117.12 117.12 bcbs pos X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 117.12 117.12 bcbs ppo X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 117.12 117.12 bcbs epo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs hmo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs hmo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs pos "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs ppo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs epo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs hmo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs hmo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs pos Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs ppo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 280.13 280.13 bcbs epo Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 337.93 337.93 bcbs hmo Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 337.93 337.93 bcbs hmo Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 337.93 337.93 bcbs pos Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 337.93 337.93 bcbs ppo Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 337.93 337.93 bcbs epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1335.61 1335.61 bcbs hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1335.61 1335.61 bcbs hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1335.61 1335.61 bcbs pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1335.61 1335.61 bcbs ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1335.61 1335.61 bcbs epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 10.78 10.78 bcbs hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 10.78 10.78 bcbs hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 10.78 10.78 bcbs pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 10.78 10.78 bcbs ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 10.78 10.78 bcbs epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 732.88 732.88 bcbs hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 732.88 732.88 bcbs hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 732.88 732.88 bcbs pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 732.88 732.88 bcbs ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 732.88 732.88 bcbs epo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 249.81 249.81 bcbs hmo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 249.81 249.81 bcbs hmo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 249.81 249.81 bcbs pos X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 249.81 249.81 bcbs ppo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 249.81 249.81 bcbs epo Follow-through X-ray of upper digestive tract with multiple serial films cpt 74248 89.7 89.7 39.82 39.82 241.01 241.01 200.84 200.84 O 89.7 89.7 bcbs hmo Follow-through X-ray of upper digestive tract with multiple serial films cpt 74248 89.7 89.7 39.82 39.82 241.01 241.01 200.84 200.84 O 89.7 89.7 bcbs hmo Follow-through X-ray of upper digestive tract with multiple serial films cpt 74248 89.7 89.7 39.82 39.82 241.01 241.01 200.84 200.84 O 89.7 89.7 bcbs pos Follow-through X-ray of upper digestive tract with multiple serial films cpt 74248 89.7 89.7 39.82 39.82 241.01 241.01 200.84 200.84 O 89.7 89.7 bcbs ppo Follow-through X-ray of upper digestive tract with multiple serial films cpt 74248 89.7 89.7 39.82 39.82 241.01 241.01 200.84 200.84 O 89.7 89.7 bcbs epo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs pos Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs ppo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 294.32 294.32 bcbs epo X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 296.91 296.91 bcbs hmo X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 296.91 296.91 bcbs hmo X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 296.91 296.91 bcbs pos X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 296.91 296.91 bcbs ppo X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 296.91 296.91 bcbs epo X-ray of large bowel with contrast cpt 74270 360.9 360.9 107.05 107.05 737.76 737.76 614.8 614.8 O 360.9 360.9 bcbs hmo X-ray of large bowel with contrast cpt 74270 360.9 360.9 107.05 107.05 737.76 737.76 614.8 614.8 O 360.9 360.9 bcbs hmo X-ray of large bowel with contrast cpt 74270 360.9 360.9 107.05 107.05 737.76 737.76 614.8 614.8 O 360.9 360.9 bcbs pos X-ray of large bowel with contrast cpt 74270 360.9 360.9 107.05 107.05 737.76 737.76 614.8 614.8 O 360.9 360.9 bcbs ppo X-ray of large bowel with contrast cpt 74270 360.9 360.9 107.05 107.05 737.76 737.76 614.8 614.8 O 360.9 360.9 bcbs epo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 318.52 318.52 bcbs hmo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 318.52 318.52 bcbs hmo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 318.52 318.52 bcbs pos X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 318.52 318.52 bcbs ppo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 318.52 318.52 bcbs epo External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 1660.63 1660.63 bcbs hmo External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 1660.63 1660.63 bcbs hmo External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 1660.63 1660.63 bcbs pos External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 1660.63 1660.63 bcbs ppo External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 1660.63 1660.63 bcbs epo Imaging of urinary tract cpt 74420 176.61 176.61 176.61 176.61 1086.29 1086.29 905.24 905.24 O 176.61 176.61 bcbs hmo Imaging of urinary tract cpt 74420 176.61 176.61 176.61 176.61 1086.29 1086.29 905.24 905.24 O 176.61 176.61 bcbs hmo Imaging of urinary tract cpt 74420 176.61 176.61 176.61 176.61 1086.29 1086.29 905.24 905.24 O 176.61 176.61 bcbs pos Imaging of urinary tract cpt 74420 176.61 176.61 176.61 176.61 1086.29 1086.29 905.24 905.24 O 176.61 176.61 bcbs ppo Imaging of urinary tract cpt 74420 176.61 176.61 176.61 176.61 1086.29 1086.29 905.24 905.24 O 176.61 176.61 bcbs epo CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 bcbs hmo CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 bcbs hmo CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 bcbs pos CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 bcbs ppo CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 bcbs epo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 358.77 358.77 bcbs hmo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 358.77 358.77 bcbs hmo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 358.77 358.77 bcbs pos Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 358.77 358.77 bcbs ppo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 358.77 358.77 bcbs epo "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 304.08 304.08 143.86 143.86 1881.6 1881.6 1568 1568 O 247.67 247.67 bcbs hmo "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 304.08 304.08 143.86 143.86 1881.6 1881.6 1568 1568 O 247.67 247.67 bcbs hmo "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 304.08 304.08 143.86 143.86 1881.6 1881.6 1568 1568 O 247.67 247.67 bcbs pos "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 304.08 304.08 143.86 143.86 1881.6 1881.6 1568 1568 O 247.67 247.67 bcbs ppo "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 304.08 304.08 143.86 143.86 1881.6 1881.6 1568 1568 O 247.67 247.67 bcbs epo "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 21516.54 21516.54 bcbs hmo "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 21516.54 21516.54 bcbs hmo "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 21516.54 21516.54 bcbs pos "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 21516.54 21516.54 bcbs ppo "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 21516.54 21516.54 bcbs epo Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2526.65 2526.65 bcbs hmo Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2526.65 2526.65 bcbs hmo Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2526.65 2526.65 bcbs pos Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2526.65 2526.65 bcbs ppo Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2526.65 2526.65 bcbs epo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 600.96 600.96 bcbs hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 600.96 600.96 bcbs hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 600.96 600.96 bcbs pos "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 600.96 600.96 bcbs ppo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 600.96 600.96 bcbs epo CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 557.59 557.59 bcbs hmo CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 557.59 557.59 bcbs hmo CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 557.59 557.59 bcbs pos CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 557.59 557.59 bcbs ppo CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 557.59 557.59 bcbs epo Radiological supervision and interpretation of imaging of artery of one arm or leg cpt 75710 2455.02 2455.02 831.17 831.17 3573.05 3573.05 2977.54 2977.54 O 831.17 831.17 bcbs hmo Radiological supervision and interpretation of imaging of artery of one arm or leg cpt 75710 2455.02 2455.02 831.17 831.17 3573.05 3573.05 2977.54 2977.54 O 831.17 831.17 bcbs hmo Radiological supervision and interpretation of imaging of artery of one arm or leg cpt 75710 2455.02 2455.02 831.17 831.17 3573.05 3573.05 2977.54 2977.54 O 831.17 831.17 bcbs pos Radiological supervision and interpretation of imaging of artery of one arm or leg cpt 75710 2455.02 2455.02 831.17 831.17 3573.05 3573.05 2977.54 2977.54 O 831.17 831.17 bcbs ppo Radiological supervision and interpretation of imaging of artery of one arm or leg cpt 75710 2455.02 2455.02 831.17 831.17 3573.05 3573.05 2977.54 2977.54 O 831.17 831.17 bcbs epo Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 1105.41 1105.41 bcbs hmo Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 1105.41 1105.41 bcbs hmo Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 1105.41 1105.41 bcbs pos Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 1105.41 1105.41 bcbs ppo Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 1105.41 1105.41 bcbs epo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 216.32 216.32 bcbs hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 216.32 216.32 bcbs hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 216.32 216.32 bcbs pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 216.32 216.32 bcbs ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 216.32 216.32 bcbs epo Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 600.96 600.96 bcbs hmo Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 600.96 600.96 bcbs hmo Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 600.96 600.96 bcbs pos Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 600.96 600.96 bcbs ppo Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 600.96 600.96 bcbs epo "Semen evaluation volume, sperm count, motility and analysis" cpt 89320 127.99 127.99 12.36 12.36 146.28 146.28 121.9 121.9 O 127.99 127.99 bcbs hmo "Semen evaluation volume, sperm count, motility and analysis" cpt 89320 127.99 127.99 12.36 12.36 146.28 146.28 121.9 121.9 O 127.99 127.99 bcbs hmo "Semen evaluation volume, sperm count, motility and analysis" cpt 89320 127.99 127.99 12.36 12.36 146.28 146.28 121.9 121.9 O 127.99 127.99 bcbs pos "Semen evaluation volume, sperm count, motility and analysis" cpt 89320 127.99 127.99 12.36 12.36 146.28 146.28 121.9 121.9 O 127.99 127.99 bcbs ppo "Semen evaluation volume, sperm count, motility and analysis" cpt 89320 127.99 127.99 12.36 12.36 146.28 146.28 121.9 121.9 O 127.99 127.99 bcbs epo Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 18.24 18.24 bcbs hmo Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 18.24 18.24 bcbs hmo Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 18.24 18.24 bcbs pos Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 18.24 18.24 bcbs ppo Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 18.24 18.24 bcbs epo Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 19.36 19.36 bcbs hmo Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 19.36 19.36 bcbs hmo Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 19.36 19.36 bcbs pos Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 19.36 19.36 bcbs ppo Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 19.36 19.36 bcbs epo Ultrasound of chest cpt 76604 282.79 282.79 282.79 282.79 625.82 625.82 521.52 521.52 O 282.79 282.79 bcbs hmo Ultrasound of chest cpt 76604 282.79 282.79 282.79 282.79 625.82 625.82 521.52 521.52 O 282.79 282.79 bcbs hmo Ultrasound of chest cpt 76604 282.79 282.79 282.79 282.79 625.82 625.82 521.52 521.52 O 282.79 282.79 bcbs pos Ultrasound of chest cpt 76604 282.79 282.79 282.79 282.79 625.82 625.82 521.52 521.52 O 282.79 282.79 bcbs ppo Ultrasound of chest cpt 76604 282.79 282.79 282.79 282.79 625.82 625.82 521.52 521.52 O 282.79 282.79 bcbs epo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 216.32 216.32 bcbs hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 216.32 216.32 bcbs hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 216.32 216.32 bcbs pos "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 216.32 216.32 bcbs ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 216.32 216.32 bcbs epo "Microscopic genetic analysis of tumor, using computer-assisted technology" cpt 88361 106.81 106.81 62.77 62.77 321.82 321.82 268.18 268.18 O 106.81 106.81 bcbs hmo "Microscopic genetic analysis of tumor, using computer-assisted technology" cpt 88361 106.81 106.81 62.77 62.77 321.82 321.82 268.18 268.18 O 106.81 106.81 bcbs hmo "Microscopic genetic analysis of tumor, using computer-assisted technology" cpt 88361 106.81 106.81 62.77 62.77 321.82 321.82 268.18 268.18 O 106.81 106.81 bcbs pos "Microscopic genetic analysis of tumor, using computer-assisted technology" cpt 88361 106.81 106.81 62.77 62.77 321.82 321.82 268.18 268.18 O 106.81 106.81 bcbs ppo "Microscopic genetic analysis of tumor, using computer-assisted technology" cpt 88361 106.81 106.81 62.77 62.77 321.82 321.82 268.18 268.18 O 106.81 106.81 bcbs epo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 142.58 142.58 bcbs hmo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 142.58 142.58 bcbs hmo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 142.58 142.58 bcbs pos "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 142.58 142.58 bcbs ppo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 142.58 142.58 bcbs epo "Special stained specimen slides to examine tissue, each additional procedure" cpt 88341 53.59 53.59 17.97 17.97 134.83 134.83 112.36 112.36 O 17.97 17.97 bcbs hmo "Special stained specimen slides to examine tissue, each additional procedure" cpt 88341 53.59 53.59 17.97 17.97 134.83 134.83 112.36 112.36 O 17.97 17.97 bcbs hmo "Special stained specimen slides to examine tissue, each additional procedure" cpt 88341 53.59 53.59 17.97 17.97 134.83 134.83 112.36 112.36 O 17.97 17.97 bcbs pos "Special stained specimen slides to examine tissue, each additional procedure" cpt 88341 53.59 53.59 17.97 17.97 134.83 134.83 112.36 112.36 O 17.97 17.97 bcbs ppo "Special stained specimen slides to examine tissue, each additional procedure" cpt 88341 53.59 53.59 17.97 17.97 134.83 134.83 112.36 112.36 O 17.97 17.97 bcbs epo "Pathology cytologic examination of specimen during surgery, initial site" cpt 88333 556.51 556.51 21.76 21.76 179.35 179.35 149.46 149.46 O 23.46 23.46 bcbs hmo "Pathology cytologic examination of specimen during surgery, initial site" cpt 88333 556.51 556.51 21.76 21.76 179.35 179.35 149.46 149.46 O 23.46 23.46 bcbs hmo "Pathology cytologic examination of specimen during surgery, initial site" cpt 88333 556.51 556.51 21.76 21.76 179.35 179.35 149.46 149.46 O 23.46 23.46 bcbs pos "Pathology cytologic examination of specimen during surgery, initial site" cpt 88333 556.51 556.51 21.76 21.76 179.35 179.35 149.46 149.46 O 23.46 23.46 bcbs ppo "Pathology cytologic examination of specimen during surgery, initial site" cpt 88333 556.51 556.51 21.76 21.76 179.35 179.35 149.46 149.46 O 23.46 23.46 bcbs epo Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 32.89 32.89 bcbs hmo Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 32.89 32.89 bcbs hmo Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 32.89 32.89 bcbs pos Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 32.89 32.89 bcbs ppo Special stained specimen slides to examine tissue including interpretation and report cpt 88313 63.17 63.17 32.89 32.89 128.47 128.47 107.06 107.06 O 32.89 32.89 bcbs epo Special stained specimen slides to identify organisms including interpretation and report cpt 88312 57.24 57.24 16.85 16.85 68.69 68.69 57.24 57.24 O 16.85 16.85 bcbs hmo Special stained specimen slides to identify organisms including interpretation and report cpt 88312 57.24 57.24 16.85 16.85 68.69 68.69 57.24 57.24 O 16.85 16.85 bcbs hmo Special stained specimen slides to identify organisms including interpretation and report cpt 88312 57.24 57.24 16.85 16.85 68.69 68.69 57.24 57.24 O 16.85 16.85 bcbs pos Special stained specimen slides to identify organisms including interpretation and report cpt 88312 57.24 57.24 16.85 16.85 68.69 68.69 57.24 57.24 O 16.85 16.85 bcbs ppo Special stained specimen slides to identify organisms including interpretation and report cpt 88312 57.24 57.24 16.85 16.85 68.69 68.69 57.24 57.24 O 16.85 16.85 bcbs epo Preparation of tissue for examination by removing any calcium present cpt 88311 43.4 43.4 7.48 7.48 49.61 49.61 41.34 41.34 O 15.58 15.58 bcbs hmo Preparation of tissue for examination by removing any calcium present cpt 88311 43.4 43.4 7.48 7.48 49.61 49.61 41.34 41.34 O 15.58 15.58 bcbs hmo Preparation of tissue for examination by removing any calcium present cpt 88311 43.4 43.4 7.48 7.48 49.61 49.61 41.34 41.34 O 15.58 15.58 bcbs pos Preparation of tissue for examination by removing any calcium present cpt 88311 43.4 43.4 7.48 7.48 49.61 49.61 41.34 41.34 O 15.58 15.58 bcbs ppo Preparation of tissue for examination by removing any calcium present cpt 88311 43.4 43.4 7.48 7.48 49.61 49.61 41.34 41.34 O 15.58 15.58 bcbs epo "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 60.63 60.63 bcbs hmo "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 60.63 60.63 bcbs hmo "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 60.63 60.63 bcbs pos "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 60.63 60.63 bcbs ppo "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 60.63 60.63 bcbs epo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 216.32 216.32 bcbs hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 216.32 216.32 bcbs hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 216.32 216.32 bcbs pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 216.32 216.32 bcbs ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 216.32 216.32 bcbs epo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 88.25 88.25 bcbs hmo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 88.25 88.25 bcbs hmo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 88.25 88.25 bcbs pos "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 88.25 88.25 bcbs ppo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 88.25 88.25 bcbs epo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 56.53 56.53 bcbs hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 56.53 56.53 bcbs hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 56.53 56.53 bcbs pos "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 56.53 56.53 bcbs ppo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 56.53 56.53 bcbs epo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 216.32 216.32 bcbs hmo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 216.32 216.32 bcbs hmo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 216.32 216.32 bcbs pos Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 216.32 216.32 bcbs ppo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 216.32 216.32 bcbs epo Pathology examination of tissue using a microscope cpt 88302 133.56 133.56 20.05 20.05 160.27 160.27 133.56 133.56 O 30.28 30.28 bcbs hmo Pathology examination of tissue using a microscope cpt 88302 133.56 133.56 20.05 20.05 160.27 160.27 133.56 133.56 O 30.28 30.28 bcbs hmo Pathology examination of tissue using a microscope cpt 88302 133.56 133.56 20.05 20.05 160.27 160.27 133.56 133.56 O 30.28 30.28 bcbs pos Pathology examination of tissue using a microscope cpt 88302 133.56 133.56 20.05 20.05 160.27 160.27 133.56 133.56 O 30.28 30.28 bcbs ppo Pathology examination of tissue using a microscope cpt 88302 133.56 133.56 20.05 20.05 160.27 160.27 133.56 133.56 O 30.28 30.28 bcbs epo "Pathology examination of tissue using a microscope, limited examination" cpt 88300 36.94 36.94 9.46 9.46 100.49 100.49 83.74 83.74 O 36.94 36.94 bcbs hmo "Pathology examination of tissue using a microscope, limited examination" cpt 88300 36.94 36.94 9.46 9.46 100.49 100.49 83.74 83.74 O 36.94 36.94 bcbs hmo "Pathology examination of tissue using a microscope, limited examination" cpt 88300 36.94 36.94 9.46 9.46 100.49 100.49 83.74 83.74 O 36.94 36.94 bcbs pos "Pathology examination of tissue using a microscope, limited examination" cpt 88300 36.94 36.94 9.46 9.46 100.49 100.49 83.74 83.74 O 36.94 36.94 bcbs ppo "Pathology examination of tissue using a microscope, limited examination" cpt 88300 36.94 36.94 9.46 9.46 100.49 100.49 83.74 83.74 O 36.94 36.94 bcbs epo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 26.39 26.39 bcbs hmo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 26.39 26.39 bcbs hmo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 26.39 26.39 bcbs pos "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 26.39 26.39 bcbs ppo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 26.39 26.39 bcbs epo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 216.32 216.32 bcbs hmo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 216.32 216.32 bcbs hmo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 216.32 216.32 bcbs pos "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 216.32 216.32 bcbs ppo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 216.32 216.32 bcbs epo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.45 58.45 bcbs hmo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.45 58.45 bcbs hmo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.45 58.45 bcbs pos Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.45 58.45 bcbs ppo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 58.45 58.45 bcbs epo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 221.85 221.85 bcbs hmo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 221.85 221.85 bcbs hmo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 221.85 221.85 bcbs pos Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 221.85 221.85 bcbs ppo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 221.85 221.85 bcbs epo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 229.19 229.19 bcbs hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 229.19 229.19 bcbs hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 229.19 229.19 bcbs pos Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 229.19 229.19 bcbs ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 229.19 229.19 bcbs epo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 22.87 22.87 bcbs hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 22.87 22.87 bcbs hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 22.87 22.87 bcbs pos "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 22.87 22.87 bcbs ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 22.87 22.87 bcbs epo "Cell examination of specimen, concentration technique" cpt 88108 111.15 111.15 29.38 29.38 226.42 226.42 188.68 188.68 O 111.15 111.15 bcbs hmo "Cell examination of specimen, concentration technique" cpt 88108 111.15 111.15 29.38 29.38 226.42 226.42 188.68 188.68 O 111.15 111.15 bcbs hmo "Cell examination of specimen, concentration technique" cpt 88108 111.15 111.15 29.38 29.38 226.42 226.42 188.68 188.68 O 111.15 111.15 bcbs pos "Cell examination of specimen, concentration technique" cpt 88108 111.15 111.15 29.38 29.38 226.42 226.42 188.68 188.68 O 111.15 111.15 bcbs ppo "Cell examination of specimen, concentration technique" cpt 88108 111.15 111.15 29.38 29.38 226.42 226.42 188.68 188.68 O 111.15 111.15 bcbs epo Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 73.57 73.57 bcbs hmo Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 73.57 73.57 bcbs hmo Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 73.57 73.57 bcbs pos Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 73.57 73.57 bcbs ppo Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 73.57 73.57 bcbs epo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) cpt 76802 84.12 84.12 18.34 18.34 132.29 132.29 110.24 110.24 O 84.12 84.12 bcbs hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) cpt 76802 84.12 84.12 18.34 18.34 132.29 132.29 110.24 110.24 O 84.12 84.12 bcbs hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) cpt 76802 84.12 84.12 18.34 18.34 132.29 132.29 110.24 110.24 O 84.12 84.12 bcbs pos Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) cpt 76802 84.12 84.12 18.34 18.34 132.29 132.29 110.24 110.24 O 84.12 84.12 bcbs ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) cpt 76802 84.12 84.12 18.34 18.34 132.29 132.29 110.24 110.24 O 84.12 84.12 bcbs epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 36.77 36.77 bcbs hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 36.77 36.77 bcbs hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 36.77 36.77 bcbs pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 36.77 36.77 bcbs ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 36.77 36.77 bcbs epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 28.91 28.91 bcbs hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 28.91 28.91 bcbs hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 28.91 28.91 bcbs pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 28.91 28.91 bcbs ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 28.91 28.91 bcbs epo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 160.06 160.06 bcbs hmo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 160.06 160.06 bcbs hmo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 160.06 160.06 bcbs pos "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 160.06 160.06 bcbs ppo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 160.06 160.06 bcbs epo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 60.01 60.01 bcbs hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 60.01 60.01 bcbs hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 60.01 60.01 bcbs pos "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 60.01 60.01 bcbs ppo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 60.01 60.01 bcbs epo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 79.43 79.43 bcbs hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 79.43 79.43 bcbs hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 79.43 79.43 bcbs pos "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 79.43 79.43 bcbs ppo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 79.43 79.43 bcbs epo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 194.63 194.63 bcbs hmo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 194.63 194.63 bcbs hmo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 194.63 194.63 bcbs pos "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 194.63 194.63 bcbs ppo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 194.63 194.63 bcbs epo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 26.28 26.28 bcbs hmo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 26.28 26.28 bcbs hmo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 26.28 26.28 bcbs pos "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 26.28 26.28 bcbs ppo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 26.28 26.28 bcbs epo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 68.65 68.65 bcbs hmo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 68.65 68.65 bcbs hmo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 68.65 68.65 bcbs pos "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 68.65 68.65 bcbs ppo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 68.65 68.65 bcbs epo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 28.45 28.45 bcbs hmo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 28.45 28.45 bcbs hmo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 28.45 28.45 bcbs pos "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 28.45 28.45 bcbs ppo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 28.45 28.45 bcbs epo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 149.81 149.81 bcbs hmo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 149.81 149.81 bcbs hmo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 149.81 149.81 bcbs pos Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 149.81 149.81 bcbs ppo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 149.81 149.81 bcbs epo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs epo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 170.26 170.26 bcbs hmo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 170.26 170.26 bcbs hmo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 170.26 170.26 bcbs pos Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 170.26 170.26 bcbs ppo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 170.26 170.26 bcbs epo "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 489.72 489.72 bcbs hmo "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 489.72 489.72 bcbs hmo "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 489.72 489.72 bcbs pos "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 489.72 489.72 bcbs ppo "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 489.72 489.72 bcbs epo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 29.68 29.68 bcbs hmo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 29.68 29.68 bcbs hmo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 29.68 29.68 bcbs pos Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 29.68 29.68 bcbs ppo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 29.68 29.68 bcbs epo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 50.36 50.36 bcbs hmo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 50.36 50.36 bcbs hmo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 50.36 50.36 bcbs pos "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 50.36 50.36 bcbs ppo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 50.36 50.36 bcbs epo "Detection test by nucleic acid for Hepatitis B virus, quantification" cpt 87517 63.64 63.64 38.11 38.11 208.8 208.8 174 174 O 63.64 63.64 bcbs hmo "Detection test by nucleic acid for Hepatitis B virus, quantification" cpt 87517 63.64 63.64 38.11 38.11 208.8 208.8 174 174 O 63.64 63.64 bcbs hmo "Detection test by nucleic acid for Hepatitis B virus, quantification" cpt 87517 63.64 63.64 38.11 38.11 208.8 208.8 174 174 O 63.64 63.64 bcbs pos "Detection test by nucleic acid for Hepatitis B virus, quantification" cpt 87517 63.64 63.64 38.11 38.11 208.8 208.8 174 174 O 63.64 63.64 bcbs ppo "Detection test by nucleic acid for Hepatitis B virus, quantification" cpt 87517 63.64 63.64 38.11 38.11 208.8 208.8 174 174 O 63.64 63.64 bcbs epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs epo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 282.79 282.79 bcbs hmo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 282.79 282.79 bcbs hmo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 282.79 282.79 bcbs pos Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 282.79 282.79 bcbs ppo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 282.79 282.79 bcbs epo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 44.91 44.91 bcbs hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 44.91 44.91 bcbs hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 44.91 44.91 bcbs pos Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 44.91 44.91 bcbs ppo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 44.91 44.91 bcbs epo Partial ultrasound of joint or other non-blood vessel structure of arm or leg cpt 76882 216.32 216.32 27.68 27.68 255.85 255.85 213.21 213.21 O 216.32 216.32 bcbs hmo Partial ultrasound of joint or other non-blood vessel structure of arm or leg cpt 76882 216.32 216.32 27.68 27.68 255.85 255.85 213.21 213.21 O 216.32 216.32 bcbs hmo Partial ultrasound of joint or other non-blood vessel structure of arm or leg cpt 76882 216.32 216.32 27.68 27.68 255.85 255.85 213.21 213.21 O 216.32 216.32 bcbs pos Partial ultrasound of joint or other non-blood vessel structure of arm or leg cpt 76882 216.32 216.32 27.68 27.68 255.85 255.85 213.21 213.21 O 216.32 216.32 bcbs ppo Partial ultrasound of joint or other non-blood vessel structure of arm or leg cpt 76882 216.32 216.32 27.68 27.68 255.85 255.85 213.21 213.21 O 216.32 216.32 bcbs epo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 207.4 207.4 bcbs hmo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 207.4 207.4 bcbs hmo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 207.4 207.4 bcbs pos Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 207.4 207.4 bcbs ppo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 207.4 207.4 bcbs epo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 bcbs hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 bcbs hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 bcbs pos Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 bcbs ppo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 116.32 116.32 bcbs epo Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 216.32 216.32 bcbs hmo Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 216.32 216.32 bcbs hmo Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 216.32 216.32 bcbs pos Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 216.32 216.32 bcbs ppo Ultrasound procedure cpt 76999 216.32 216.32 70.7 70.7 256.94 256.94 214.12 214.12 O 216.32 216.32 bcbs epo "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 208.53 208.53 bcbs hmo "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 208.53 208.53 bcbs hmo "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 208.53 208.53 bcbs pos "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 208.53 208.53 bcbs ppo "Fluoroscopic guidance for insertion, replacement or removal of central venous access device" cpt 77001 424.02 424.02 208.53 208.53 862.42 862.42 718.68 718.68 O 208.53 208.53 bcbs epo Fluoroscopic guidance for insertion of needle cpt 77002 470.47 470.47 470.47 470.47 1854.58 1854.58 1545.48 1545.48 O 470.47 470.47 bcbs hmo Fluoroscopic guidance for insertion of needle cpt 77002 470.47 470.47 470.47 470.47 1854.58 1854.58 1545.48 1545.48 O 470.47 470.47 bcbs hmo Fluoroscopic guidance for insertion of needle cpt 77002 470.47 470.47 470.47 470.47 1854.58 1854.58 1545.48 1545.48 O 470.47 470.47 bcbs pos Fluoroscopic guidance for insertion of needle cpt 77002 470.47 470.47 470.47 470.47 1854.58 1854.58 1545.48 1545.48 O 470.47 470.47 bcbs ppo Fluoroscopic guidance for insertion of needle cpt 77002 470.47 470.47 470.47 470.47 1854.58 1854.58 1545.48 1545.48 O 470.47 470.47 bcbs epo MRI of both breasts with and without contrast cpt 77049 871.56 871.56 244.47 244.47 3246.14 3246.14 2705.12 2705.12 O 871.56 871.56 bcbs hmo MRI of both breasts with and without contrast cpt 77049 871.56 871.56 244.47 244.47 3246.14 3246.14 2705.12 2705.12 O 871.56 871.56 bcbs hmo MRI of both breasts with and without contrast cpt 77049 871.56 871.56 244.47 244.47 3246.14 3246.14 2705.12 2705.12 O 871.56 871.56 bcbs pos MRI of both breasts with and without contrast cpt 77049 871.56 871.56 244.47 244.47 3246.14 3246.14 2705.12 2705.12 O 871.56 871.56 bcbs ppo MRI of both breasts with and without contrast cpt 77049 871.56 871.56 244.47 244.47 3246.14 3246.14 2705.12 2705.12 O 871.56 871.56 bcbs epo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 167.23 167.23 bcbs hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 167.23 167.23 bcbs hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 167.23 167.23 bcbs pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 167.23 167.23 bcbs ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 167.23 167.23 bcbs epo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 13.82 13.82 bcbs hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 13.82 13.82 bcbs hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 13.82 13.82 bcbs pos "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 13.82 13.82 bcbs ppo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 13.82 13.82 bcbs epo "ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with mcc" ms-drg 61 40043.51 40043.51 11478.18 11478.18 64676.57 64676.57 53897.14 53897.14 I 40043.51 40043.51 bcbs hmo "ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with mcc" ms-drg 61 40043.51 40043.51 11478.18 11478.18 64676.57 64676.57 53897.14 53897.14 I 40043.51 40043.51 bcbs hmo "ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with mcc" ms-drg 61 40043.51 40043.51 11478.18 11478.18 64676.57 64676.57 53897.14 53897.14 I 40043.51 40043.51 bcbs pos "ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with mcc" ms-drg 61 40043.51 40043.51 11478.18 11478.18 64676.57 64676.57 53897.14 53897.14 I 40043.51 40043.51 bcbs ppo "ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with mcc" ms-drg 61 40043.51 40043.51 11478.18 11478.18 64676.57 64676.57 53897.14 53897.14 I 40043.51 40043.51 bcbs epo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 38.7 38.7 bcbs epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 27.18 27.18 bcbs epo X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 61.44 61.44 bcbs hmo X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 61.44 61.44 bcbs hmo X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 61.44 61.44 bcbs pos X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 61.44 61.44 bcbs ppo X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 61.44 61.44 bcbs epo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs pos Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs ppo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs epo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 106.95 106.95 bcbs hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 106.95 106.95 bcbs hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 106.95 106.95 bcbs pos "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 106.95 106.95 bcbs ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 106.95 106.95 bcbs epo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 15.73 15.73 bcbs hmo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 15.73 15.73 bcbs hmo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 15.73 15.73 bcbs pos Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 15.73 15.73 bcbs ppo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 15.73 15.73 bcbs epo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.51 10.51 bcbs hmo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.51 10.51 bcbs hmo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.51 10.51 bcbs pos Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.51 10.51 bcbs ppo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.51 10.51 bcbs epo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 24.45 24.45 bcbs hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 24.45 24.45 bcbs hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 24.45 24.45 bcbs pos "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 24.45 24.45 bcbs ppo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 24.45 24.45 bcbs epo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 588.1 588.1 bcbs hmo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 588.1 588.1 bcbs hmo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 588.1 588.1 bcbs pos "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 588.1 588.1 bcbs ppo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 588.1 588.1 bcbs epo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 113.27 113.27 bcbs hmo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 113.27 113.27 bcbs hmo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 113.27 113.27 bcbs pos "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 113.27 113.27 bcbs ppo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 113.27 113.27 bcbs epo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1016.1 1016.1 bcbs hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1016.1 1016.1 bcbs hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1016.1 1016.1 bcbs pos "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1016.1 1016.1 bcbs ppo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1016.1 1016.1 bcbs epo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs pos Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs ppo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 10.43 10.43 bcbs epo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 59.47 59.47 bcbs hmo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 59.47 59.47 bcbs hmo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 59.47 59.47 bcbs pos Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 59.47 59.47 bcbs ppo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 59.47 59.47 bcbs epo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1003.61 1003.61 bcbs hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1003.61 1003.61 bcbs hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1003.61 1003.61 bcbs pos "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1003.61 1003.61 bcbs ppo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1003.61 1003.61 bcbs epo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 20.63 20.63 bcbs hmo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 20.63 20.63 bcbs hmo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 20.63 20.63 bcbs pos Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 20.63 20.63 bcbs ppo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 20.63 20.63 bcbs epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 10.56 10.56 bcbs hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 10.56 10.56 bcbs hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 10.56 10.56 bcbs pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 10.56 10.56 bcbs ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 10.56 10.56 bcbs epo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 143.46 143.46 bcbs hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 143.46 143.46 bcbs hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 143.46 143.46 bcbs pos Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 143.46 143.46 bcbs ppo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 143.46 143.46 bcbs epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 7.8 7.8 bcbs hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 7.8 7.8 bcbs hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 7.8 7.8 bcbs pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 7.8 7.8 bcbs ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 7.8 7.8 bcbs epo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 16.24 16.24 bcbs hmo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 16.24 16.24 bcbs hmo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 16.24 16.24 bcbs pos Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 16.24 16.24 bcbs ppo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 16.24 16.24 bcbs epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 7.27 7.27 bcbs hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 7.27 7.27 bcbs hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 7.27 7.27 bcbs pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 7.27 7.27 bcbs ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 7.27 7.27 bcbs epo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1262.13 1262.13 bcbs hmo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1262.13 1262.13 bcbs hmo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1262.13 1262.13 bcbs pos Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1262.13 1262.13 bcbs ppo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1262.13 1262.13 bcbs epo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 15.25 15.25 bcbs hmo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 15.25 15.25 bcbs hmo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 15.25 15.25 bcbs pos Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 15.25 15.25 bcbs ppo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 15.25 15.25 bcbs epo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 264.62 264.62 bcbs hmo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 264.62 264.62 bcbs hmo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 264.62 264.62 bcbs pos Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 264.62 264.62 bcbs ppo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 264.62 264.62 bcbs epo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 21.32 21.32 bcbs hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 21.32 21.32 bcbs hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 21.32 21.32 bcbs pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 21.32 21.32 bcbs ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 21.32 21.32 bcbs epo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 21.84 21.84 bcbs hmo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 21.84 21.84 bcbs hmo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 21.84 21.84 bcbs pos Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 21.84 21.84 bcbs ppo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 21.84 21.84 bcbs epo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 11.68 11.68 bcbs hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 11.68 11.68 bcbs hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 11.68 11.68 bcbs pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 11.68 11.68 bcbs ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 11.68 11.68 bcbs epo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 20.43 20.43 bcbs hmo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 20.43 20.43 bcbs hmo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 20.43 20.43 bcbs pos "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 20.43 20.43 bcbs ppo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 20.43 20.43 bcbs epo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 318.89 318.89 bcbs hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 318.89 318.89 bcbs hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 318.89 318.89 bcbs pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 318.89 318.89 bcbs ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 318.89 318.89 bcbs epo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 14.94 14.94 bcbs hmo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 14.94 14.94 bcbs hmo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 14.94 14.94 bcbs pos "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 14.94 14.94 bcbs ppo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 14.94 14.94 bcbs epo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 188.32 188.32 bcbs hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 188.32 188.32 bcbs hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 188.32 188.32 bcbs pos Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 188.32 188.32 bcbs ppo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 188.32 188.32 bcbs epo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.14 9.14 bcbs hmo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.14 9.14 bcbs hmo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.14 9.14 bcbs pos "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.14 9.14 bcbs ppo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.14 9.14 bcbs epo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 13.91 13.91 bcbs hmo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 13.91 13.91 bcbs hmo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 13.91 13.91 bcbs pos Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 13.91 13.91 bcbs ppo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 13.91 13.91 bcbs epo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 47.62 47.62 bcbs hmo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 47.62 47.62 bcbs hmo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 47.62 47.62 bcbs pos Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 47.62 47.62 bcbs ppo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 47.62 47.62 bcbs epo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 308.14 308.14 bcbs hmo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 308.14 308.14 bcbs hmo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 308.14 308.14 bcbs pos Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 308.14 308.14 bcbs ppo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 308.14 308.14 bcbs epo "Blood unit compatibility test, antiglobulin technique" cpt 86922 62.47 62.47 42.14 42.14 320.54 320.54 267.12 267.12 O 62.47 62.47 bcbs hmo "Blood unit compatibility test, antiglobulin technique" cpt 86922 62.47 62.47 42.14 42.14 320.54 320.54 267.12 267.12 O 62.47 62.47 bcbs hmo "Blood unit compatibility test, antiglobulin technique" cpt 86922 62.47 62.47 42.14 42.14 320.54 320.54 267.12 267.12 O 62.47 62.47 bcbs pos "Blood unit compatibility test, antiglobulin technique" cpt 86922 62.47 62.47 42.14 42.14 320.54 320.54 267.12 267.12 O 62.47 62.47 bcbs ppo "Blood unit compatibility test, antiglobulin technique" cpt 86922 62.47 62.47 42.14 42.14 320.54 320.54 267.12 267.12 O 62.47 62.47 bcbs epo "Blood unit compatibility test, incubation technique" cpt 86921 36.44 36.44 18.72 18.72 82.68 82.68 68.9 68.9 O 36.44 36.44 bcbs hmo "Blood unit compatibility test, incubation technique" cpt 86921 36.44 36.44 18.72 18.72 82.68 82.68 68.9 68.9 O 36.44 36.44 bcbs hmo "Blood unit compatibility test, incubation technique" cpt 86921 36.44 36.44 18.72 18.72 82.68 82.68 68.9 68.9 O 36.44 36.44 bcbs pos "Blood unit compatibility test, incubation technique" cpt 86921 36.44 36.44 18.72 18.72 82.68 82.68 68.9 68.9 O 36.44 36.44 bcbs ppo "Blood unit compatibility test, incubation technique" cpt 86921 36.44 36.44 18.72 18.72 82.68 82.68 68.9 68.9 O 36.44 36.44 bcbs epo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 231.69 231.69 bcbs hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 231.69 231.69 bcbs hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 231.69 231.69 bcbs pos "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 231.69 231.69 bcbs ppo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 231.69 231.69 bcbs epo "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 717.88 717.88 bcbs hmo "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 717.88 717.88 bcbs hmo "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 717.88 717.88 bcbs pos "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 717.88 717.88 bcbs ppo "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 717.88 717.88 bcbs epo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 493.14 493.14 bcbs hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 493.14 493.14 bcbs hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 493.14 493.14 bcbs pos "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 493.14 493.14 bcbs ppo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 493.14 493.14 bcbs epo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.11 13.11 bcbs hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.11 13.11 bcbs hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.11 13.11 bcbs pos Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.11 13.11 bcbs ppo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.11 13.11 bcbs epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.76 19.76 bcbs hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.76 19.76 bcbs hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.76 19.76 bcbs pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.76 19.76 bcbs ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.76 19.76 bcbs epo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 155.94 155.94 bcbs hmo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 155.94 155.94 bcbs hmo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 155.94 155.94 bcbs pos Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 155.94 155.94 bcbs ppo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 155.94 155.94 bcbs epo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 45.6 45.6 bcbs hmo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 45.6 45.6 bcbs hmo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 45.6 45.6 bcbs pos "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 45.6 45.6 bcbs ppo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 45.6 45.6 bcbs epo Identification of red blood cell antibodies cpt 86870 251.07 251.07 23.42 23.42 310.8 310.8 259 259 O 62.53 62.53 bcbs hmo Identification of red blood cell antibodies cpt 86870 251.07 251.07 23.42 23.42 310.8 310.8 259 259 O 62.53 62.53 bcbs hmo Identification of red blood cell antibodies cpt 86870 251.07 251.07 23.42 23.42 310.8 310.8 259 259 O 62.53 62.53 bcbs pos Identification of red blood cell antibodies cpt 86870 251.07 251.07 23.42 23.42 310.8 310.8 259 259 O 62.53 62.53 bcbs ppo Identification of red blood cell antibodies cpt 86870 251.07 251.07 23.42 23.42 310.8 310.8 259 259 O 62.53 62.53 bcbs epo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 14.68 14.68 bcbs hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 14.68 14.68 bcbs hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 14.68 14.68 bcbs pos Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 14.68 14.68 bcbs ppo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 14.68 14.68 bcbs epo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 660.29 660.29 bcbs hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 660.29 660.29 bcbs hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 660.29 660.29 bcbs pos "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 660.29 660.29 bcbs ppo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 660.29 660.29 bcbs epo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 17.59 17.59 bcbs hmo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 17.59 17.59 bcbs hmo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 17.59 17.59 bcbs pos "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 17.59 17.59 bcbs ppo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 17.59 17.59 bcbs epo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.53 26.53 bcbs hmo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.53 26.53 bcbs hmo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.53 26.53 bcbs pos Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.53 26.53 bcbs ppo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.53 26.53 bcbs epo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 21.21 21.21 bcbs hmo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 21.21 21.21 bcbs hmo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 21.21 21.21 bcbs pos Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 21.21 21.21 bcbs ppo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 21.21 21.21 bcbs epo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.85 15.85 bcbs hmo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.85 15.85 bcbs hmo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.85 15.85 bcbs pos Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.85 15.85 bcbs ppo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.85 15.85 bcbs epo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 7.94 7.94 bcbs hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 7.94 7.94 bcbs hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 7.94 7.94 bcbs pos Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 7.94 7.94 bcbs ppo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 7.94 7.94 bcbs epo Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 757.43 757.43 bcbs hmo Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 757.43 757.43 bcbs hmo Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 757.43 757.43 bcbs pos Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 757.43 757.43 bcbs ppo Thyroid imaging with vascular flow cpt 78014 757.43 757.43 273.97 273.97 1326.7 1326.7 1105.58 1105.58 O 757.43 757.43 bcbs epo Imaging of lymphatic tissue and lymph node cpt 78195 368.89 368.89 368.89 368.89 2732.4 2732.4 2277 2277 O 368.89 368.89 bcbs hmo Imaging of lymphatic tissue and lymph node cpt 78195 368.89 368.89 368.89 368.89 2732.4 2732.4 2277 2277 O 368.89 368.89 bcbs hmo Imaging of lymphatic tissue and lymph node cpt 78195 368.89 368.89 368.89 368.89 2732.4 2732.4 2277 2277 O 368.89 368.89 bcbs pos Imaging of lymphatic tissue and lymph node cpt 78195 368.89 368.89 368.89 368.89 2732.4 2732.4 2277 2277 O 368.89 368.89 bcbs ppo Imaging of lymphatic tissue and lymph node cpt 78195 368.89 368.89 368.89 368.89 2732.4 2732.4 2277 2277 O 368.89 368.89 bcbs epo "Analysis for antibody, Treponema pallidum" cpt 86780 42.59 42.59 11.78 11.78 357.43 357.43 297.86 297.86 O 42.59 42.59 bcbs hmo "Analysis for antibody, Treponema pallidum" cpt 86780 42.59 42.59 11.78 11.78 357.43 357.43 297.86 297.86 O 42.59 42.59 bcbs hmo "Analysis for antibody, Treponema pallidum" cpt 86780 42.59 42.59 11.78 11.78 357.43 357.43 297.86 297.86 O 42.59 42.59 bcbs pos "Analysis for antibody, Treponema pallidum" cpt 86780 42.59 42.59 11.78 11.78 357.43 357.43 297.86 297.86 O 42.59 42.59 bcbs ppo "Analysis for antibody, Treponema pallidum" cpt 86780 42.59 42.59 11.78 11.78 357.43 357.43 297.86 297.86 O 42.59 42.59 bcbs epo Analysis for antibody (IgM) to Toxoplasma (parasite) cpt 86778 14.12 14.12 14.06 14.06 164.09 164.09 136.74 136.74 O 14.06 14.06 bcbs hmo Analysis for antibody (IgM) to Toxoplasma (parasite) cpt 86778 14.12 14.12 14.06 14.06 164.09 164.09 136.74 136.74 O 14.06 14.06 bcbs hmo Analysis for antibody (IgM) to Toxoplasma (parasite) cpt 86778 14.12 14.12 14.06 14.06 164.09 164.09 136.74 136.74 O 14.06 14.06 bcbs pos Analysis for antibody (IgM) to Toxoplasma (parasite) cpt 86778 14.12 14.12 14.06 14.06 164.09 164.09 136.74 136.74 O 14.06 14.06 bcbs ppo Analysis for antibody (IgM) to Toxoplasma (parasite) cpt 86778 14.12 14.12 14.06 14.06 164.09 164.09 136.74 136.74 O 14.06 14.06 bcbs epo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 890.61 890.61 bcbs hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 890.61 890.61 bcbs hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 890.61 890.61 bcbs pos Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 890.61 890.61 bcbs ppo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 890.61 890.61 bcbs epo Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 13.81 13.81 bcbs hmo Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 13.81 13.81 bcbs hmo Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 13.81 13.81 bcbs pos Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 13.81 13.81 bcbs ppo Analysis for antibody to Toxoplasma (parasite) cpt 86777 83.27 83.27 13.81 13.81 164.09 164.09 136.74 136.74 O 13.81 13.81 bcbs epo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 522.98 522.98 bcbs hmo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 522.98 522.98 bcbs hmo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 522.98 522.98 bcbs pos "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 522.98 522.98 bcbs ppo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 522.98 522.98 bcbs epo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 676.94 676.94 bcbs hmo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 676.94 676.94 bcbs hmo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 676.94 676.94 bcbs pos "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 676.94 676.94 bcbs ppo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 676.94 676.94 bcbs epo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 17.41 17.41 bcbs hmo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 17.41 17.41 bcbs hmo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 17.41 17.41 bcbs pos Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 17.41 17.41 bcbs ppo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 17.41 17.41 bcbs epo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 6.66 6.66 bcbs hmo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 6.66 6.66 bcbs hmo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 6.66 6.66 bcbs pos Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 6.66 6.66 bcbs ppo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 6.66 6.66 bcbs epo Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 20.99 20.99 bcbs hmo Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 20.99 20.99 bcbs hmo Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 20.99 20.99 bcbs pos Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 20.99 20.99 bcbs ppo Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 20.99 20.99 bcbs epo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 36305.41 36305.41 bcbs hmo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 36305.41 36305.41 bcbs hmo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 36305.41 36305.41 bcbs pos Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 36305.41 36305.41 bcbs ppo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 36305.41 36305.41 bcbs epo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 16.72 16.72 bcbs hmo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 16.72 16.72 bcbs hmo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 16.72 16.72 bcbs pos Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 16.72 16.72 bcbs ppo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 16.72 16.72 bcbs epo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 23.03 23.03 bcbs hmo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 23.03 23.03 bcbs hmo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 23.03 23.03 bcbs pos Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 23.03 23.03 bcbs ppo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 23.03 23.03 bcbs epo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 23.8 23.8 bcbs hmo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 23.8 23.8 bcbs hmo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 23.8 23.8 bcbs pos Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 23.8 23.8 bcbs ppo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 23.8 23.8 bcbs epo Analysis for antibody to histoplasma (fungus) cpt 86698 22.57 22.57 13.66 13.66 228 228 190 190 O 22.57 22.57 bcbs hmo Analysis for antibody to histoplasma (fungus) cpt 86698 22.57 22.57 13.66 13.66 228 228 190 190 O 22.57 22.57 bcbs hmo Analysis for antibody to histoplasma (fungus) cpt 86698 22.57 22.57 13.66 13.66 228 228 190 190 O 22.57 22.57 bcbs pos Analysis for antibody to histoplasma (fungus) cpt 86698 22.57 22.57 13.66 13.66 228 228 190 190 O 22.57 22.57 bcbs ppo Analysis for antibody to histoplasma (fungus) cpt 86698 22.57 22.57 13.66 13.66 228 228 190 190 O 22.57 22.57 bcbs epo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 25.1 25.1 bcbs hmo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 25.1 25.1 bcbs hmo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 25.1 25.1 bcbs pos "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 25.1 25.1 bcbs ppo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 25.1 25.1 bcbs epo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 995.51 995.51 bcbs hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 995.51 995.51 bcbs hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 995.51 995.51 bcbs pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 995.51 995.51 bcbs ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 995.51 995.51 bcbs epo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 17.83 17.83 bcbs hmo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 17.83 17.83 bcbs hmo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 17.83 17.83 bcbs pos "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 17.83 17.83 bcbs ppo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 17.83 17.83 bcbs epo Analysis for antibody (IgM) to Cytomegalovirus (CMV) cpt 86645 21.06 21.06 14.99 14.99 77.59 77.59 64.66 64.66 O 21.06 21.06 bcbs hmo Analysis for antibody (IgM) to Cytomegalovirus (CMV) cpt 86645 21.06 21.06 14.99 14.99 77.59 77.59 64.66 64.66 O 21.06 21.06 bcbs hmo Analysis for antibody (IgM) to Cytomegalovirus (CMV) cpt 86645 21.06 21.06 14.99 14.99 77.59 77.59 64.66 64.66 O 21.06 21.06 bcbs pos Analysis for antibody (IgM) to Cytomegalovirus (CMV) cpt 86645 21.06 21.06 14.99 14.99 77.59 77.59 64.66 64.66 O 21.06 21.06 bcbs ppo Analysis for antibody (IgM) to Cytomegalovirus (CMV) cpt 86645 21.06 21.06 14.99 14.99 77.59 77.59 64.66 64.66 O 21.06 21.06 bcbs epo Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 23.13 23.13 bcbs hmo Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 23.13 23.13 bcbs hmo Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 23.13 23.13 bcbs pos Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 23.13 23.13 bcbs ppo Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 23.13 23.13 bcbs epo Analysis for antibody to Coccidioides (bacteria) cpt 86635 13.84 13.84 11.36 11.36 100.49 100.49 83.74 83.74 O 13.84 13.84 bcbs hmo Analysis for antibody to Coccidioides (bacteria) cpt 86635 13.84 13.84 11.36 11.36 100.49 100.49 83.74 83.74 O 13.84 13.84 bcbs hmo Analysis for antibody to Coccidioides (bacteria) cpt 86635 13.84 13.84 11.36 11.36 100.49 100.49 83.74 83.74 O 13.84 13.84 bcbs pos Analysis for antibody to Coccidioides (bacteria) cpt 86635 13.84 13.84 11.36 11.36 100.49 100.49 83.74 83.74 O 13.84 13.84 bcbs ppo Analysis for antibody to Coccidioides (bacteria) cpt 86635 13.84 13.84 11.36 11.36 100.49 100.49 83.74 83.74 O 13.84 13.84 bcbs epo Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 44.5 44.5 bcbs hmo Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 44.5 44.5 bcbs hmo Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 44.5 44.5 bcbs pos Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 44.5 44.5 bcbs ppo Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 44.5 44.5 bcbs epo Analysis for antibody to blastomyces (fungus) cpt 86612 12.77 12.77 5.08 5.08 94.8 94.8 79 79 O 5.08 5.08 bcbs hmo Analysis for antibody to blastomyces (fungus) cpt 86612 12.77 12.77 5.08 5.08 94.8 94.8 79 79 O 5.08 5.08 bcbs hmo Analysis for antibody to blastomyces (fungus) cpt 86612 12.77 12.77 5.08 5.08 94.8 94.8 79 79 O 5.08 5.08 bcbs pos Analysis for antibody to blastomyces (fungus) cpt 86612 12.77 12.77 5.08 5.08 94.8 94.8 79 79 O 5.08 5.08 bcbs ppo Analysis for antibody to blastomyces (fungus) cpt 86612 12.77 12.77 5.08 5.08 94.8 94.8 79 79 O 5.08 5.08 bcbs epo Analysis for antibody bacteria cpt 86609 13.9 13.9 13.9 13.9 38.64 38.64 32.2 32.2 O 13.9 13.9 bcbs hmo Analysis for antibody bacteria cpt 86609 13.9 13.9 13.9 13.9 38.64 38.64 32.2 32.2 O 13.9 13.9 bcbs hmo Analysis for antibody bacteria cpt 86609 13.9 13.9 13.9 13.9 38.64 38.64 32.2 32.2 O 13.9 13.9 bcbs pos Analysis for antibody bacteria cpt 86609 13.9 13.9 13.9 13.9 38.64 38.64 32.2 32.2 O 13.9 13.9 bcbs ppo Analysis for antibody bacteria cpt 86609 13.9 13.9 13.9 13.9 38.64 38.64 32.2 32.2 O 13.9 13.9 bcbs epo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 2549.99 2549.99 bcbs hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 2549.99 2549.99 bcbs hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 2549.99 2549.99 bcbs pos Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 2549.99 2549.99 bcbs ppo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 2549.99 2549.99 bcbs epo Nuclear medicine study with CT imaging whole body cpt 78816 2822.36 2822.36 1257.95 1257.95 8147.16 8147.16 6789.3 6789.3 O 2822.36 2822.36 bcbs hmo Nuclear medicine study with CT imaging whole body cpt 78816 2822.36 2822.36 1257.95 1257.95 8147.16 8147.16 6789.3 6789.3 O 2822.36 2822.36 bcbs hmo Nuclear medicine study with CT imaging whole body cpt 78816 2822.36 2822.36 1257.95 1257.95 8147.16 8147.16 6789.3 6789.3 O 2822.36 2822.36 bcbs pos Nuclear medicine study with CT imaging whole body cpt 78816 2822.36 2822.36 1257.95 1257.95 8147.16 8147.16 6789.3 6789.3 O 2822.36 2822.36 bcbs ppo Nuclear medicine study with CT imaging whole body cpt 78816 2822.36 2822.36 1257.95 1257.95 8147.16 8147.16 6789.3 6789.3 O 2822.36 2822.36 bcbs epo Analysis for antibody to aspergillus (fungus) cpt 86606 16.25 16.25 16.25 16.25 102 102 85 85 O 16.25 16.25 bcbs hmo Analysis for antibody to aspergillus (fungus) cpt 86606 16.25 16.25 16.25 16.25 102 102 85 85 O 16.25 16.25 bcbs hmo Analysis for antibody to aspergillus (fungus) cpt 86606 16.25 16.25 16.25 16.25 102 102 85 85 O 16.25 16.25 bcbs pos Analysis for antibody to aspergillus (fungus) cpt 86606 16.25 16.25 16.25 16.25 102 102 85 85 O 16.25 16.25 bcbs ppo Analysis for antibody to aspergillus (fungus) cpt 86606 16.25 16.25 16.25 16.25 102 102 85 85 O 16.25 16.25 bcbs epo Oral administration of radioactive material therapy agent cpt 79005 494.33 494.33 42.5 42.5 2750.06 2750.06 2291.72 2291.72 O 494.33 494.33 bcbs hmo Oral administration of radioactive material therapy agent cpt 79005 494.33 494.33 42.5 42.5 2750.06 2750.06 2291.72 2291.72 O 494.33 494.33 bcbs hmo Oral administration of radioactive material therapy agent cpt 79005 494.33 494.33 42.5 42.5 2750.06 2750.06 2291.72 2291.72 O 494.33 494.33 bcbs pos Oral administration of radioactive material therapy agent cpt 79005 494.33 494.33 42.5 42.5 2750.06 2750.06 2291.72 2291.72 O 494.33 494.33 bcbs ppo Oral administration of radioactive material therapy agent cpt 79005 494.33 494.33 42.5 42.5 2750.06 2750.06 2291.72 2291.72 O 494.33 494.33 bcbs epo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 6 6 bcbs hmo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 6 6 bcbs hmo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 6 6 bcbs pos Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 6 6 bcbs ppo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 6 6 bcbs epo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 33.45 33.45 bcbs hmo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 33.45 33.45 bcbs hmo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 33.45 33.45 bcbs pos "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 33.45 33.45 bcbs ppo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 33.45 33.45 bcbs epo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 47.79 47.79 bcbs hmo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 47.79 47.79 bcbs hmo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 47.79 47.79 bcbs pos General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 47.79 47.79 bcbs ppo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 47.79 47.79 bcbs epo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 30.33 30.33 bcbs hmo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 30.33 30.33 bcbs hmo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 30.33 30.33 bcbs pos "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 30.33 30.33 bcbs ppo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 30.33 30.33 bcbs epo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.91 6.91 bcbs hmo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.91 6.91 bcbs hmo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.91 6.91 bcbs pos Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.91 6.91 bcbs ppo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.91 6.91 bcbs epo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 5.66 5.66 bcbs hmo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 5.66 5.66 bcbs hmo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 5.66 5.66 bcbs pos Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 5.66 5.66 bcbs ppo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 5.66 5.66 bcbs epo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.56 14.56 bcbs hmo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.56 14.56 bcbs hmo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.56 14.56 bcbs pos Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.56 14.56 bcbs ppo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.56 14.56 bcbs epo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 31.4 31.4 bcbs hmo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 31.4 31.4 bcbs hmo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 31.4 31.4 bcbs pos Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 31.4 31.4 bcbs ppo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 31.4 31.4 bcbs epo Islet cell (pancreas) antibody measurement cpt 86341 24.9 24.9 20.97 20.97 150.1 150.1 125.08 125.08 O 24.9 24.9 bcbs hmo Islet cell (pancreas) antibody measurement cpt 86341 24.9 24.9 20.97 20.97 150.1 150.1 125.08 125.08 O 24.9 24.9 bcbs hmo Islet cell (pancreas) antibody measurement cpt 86341 24.9 24.9 20.97 20.97 150.1 150.1 125.08 125.08 O 24.9 24.9 bcbs pos Islet cell (pancreas) antibody measurement cpt 86341 24.9 24.9 20.97 20.97 150.1 150.1 125.08 125.08 O 24.9 24.9 bcbs ppo Islet cell (pancreas) antibody measurement cpt 86341 24.9 24.9 20.97 20.97 150.1 150.1 125.08 125.08 O 24.9 24.9 bcbs epo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 21.05 21.05 bcbs hmo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 21.05 21.05 bcbs hmo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 21.05 21.05 bcbs pos Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 21.05 21.05 bcbs ppo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 21.05 21.05 bcbs epo Immunologic analysis for detection of antigen or antibody cpt 86331 12.93 12.93 12.93 12.93 35.94 35.94 29.95 29.95 O 12.93 12.93 bcbs hmo Immunologic analysis for detection of antigen or antibody cpt 86331 12.93 12.93 12.93 12.93 35.94 35.94 29.95 29.95 O 12.93 12.93 bcbs hmo Immunologic analysis for detection of antigen or antibody cpt 86331 12.93 12.93 12.93 12.93 35.94 35.94 29.95 29.95 O 12.93 12.93 bcbs pos Immunologic analysis for detection of antigen or antibody cpt 86331 12.93 12.93 12.93 12.93 35.94 35.94 29.95 29.95 O 12.93 12.93 bcbs ppo Immunologic analysis for detection of antigen or antibody cpt 86331 12.93 12.93 12.93 12.93 35.94 35.94 29.95 29.95 O 12.93 12.93 bcbs epo "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 15.53 15.53 bcbs hmo "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 15.53 15.53 bcbs hmo "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 15.53 15.53 bcbs pos "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 15.53 15.53 bcbs ppo "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 15.53 15.53 bcbs epo "Detection of infectious agent antibody, quantitative" cpt 86317 14.99 14.99 9.85 9.85 160.27 160.27 133.56 133.56 O 9.85 9.85 bcbs hmo "Detection of infectious agent antibody, quantitative" cpt 86317 14.99 14.99 9.85 9.85 160.27 160.27 133.56 133.56 O 9.85 9.85 bcbs hmo "Detection of infectious agent antibody, quantitative" cpt 86317 14.99 14.99 9.85 9.85 160.27 160.27 133.56 133.56 O 9.85 9.85 bcbs pos "Detection of infectious agent antibody, quantitative" cpt 86317 14.99 14.99 9.85 9.85 160.27 160.27 133.56 133.56 O 9.85 9.85 bcbs ppo "Detection of infectious agent antibody, quantitative" cpt 86317 14.99 14.99 9.85 9.85 160.27 160.27 133.56 133.56 O 9.85 9.85 bcbs epo Screening test for mononucleosis (mono) cpt 86308 21.25 21.25 4.61 4.61 44.52 44.52 37.1 37.1 O 21.25 21.25 bcbs hmo Screening test for mononucleosis (mono) cpt 86308 21.25 21.25 4.61 4.61 44.52 44.52 37.1 37.1 O 21.25 21.25 bcbs hmo Screening test for mononucleosis (mono) cpt 86308 21.25 21.25 4.61 4.61 44.52 44.52 37.1 37.1 O 21.25 21.25 bcbs pos Screening test for mononucleosis (mono) cpt 86308 21.25 21.25 4.61 4.61 44.52 44.52 37.1 37.1 O 21.25 21.25 bcbs ppo Screening test for mononucleosis (mono) cpt 86308 21.25 21.25 4.61 4.61 44.52 44.52 37.1 37.1 O 21.25 21.25 bcbs epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 43.28 43.28 bcbs hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 43.28 43.28 bcbs hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 43.28 43.28 bcbs pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 43.28 43.28 bcbs ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 43.28 43.28 bcbs epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 79.34 79.34 bcbs hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 79.34 79.34 bcbs hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 79.34 79.34 bcbs pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 79.34 79.34 bcbs ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 79.34 79.34 bcbs epo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 47.79 47.79 bcbs hmo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 47.79 47.79 bcbs hmo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 47.79 47.79 bcbs pos "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 47.79 47.79 bcbs ppo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 47.79 47.79 bcbs epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 77.89 77.89 bcbs hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 77.89 77.89 bcbs hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 77.89 77.89 bcbs pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 77.89 77.89 bcbs ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 77.89 77.89 bcbs epo Screening test for antibody to noninfectious agent cpt 86255 12.1 12.1 8.25 8.25 94.8 94.8 79 79 O 8.25 8.25 bcbs hmo Screening test for antibody to noninfectious agent cpt 86255 12.1 12.1 8.25 8.25 94.8 94.8 79 79 O 8.25 8.25 bcbs hmo Screening test for antibody to noninfectious agent cpt 86255 12.1 12.1 8.25 8.25 94.8 94.8 79 79 O 8.25 8.25 bcbs pos Screening test for antibody to noninfectious agent cpt 86255 12.1 12.1 8.25 8.25 94.8 94.8 79 79 O 8.25 8.25 bcbs ppo Screening test for antibody to noninfectious agent cpt 86255 12.1 12.1 8.25 8.25 94.8 94.8 79 79 O 8.25 8.25 bcbs epo Phenobarbital level cpt 80184 17.41 17.41 13.61 13.61 109.26 109.26 91.05 91.05 O 17.41 17.41 bcbs hmo Phenobarbital level cpt 80184 17.41 17.41 13.61 13.61 109.26 109.26 91.05 91.05 O 17.41 17.41 bcbs hmo Phenobarbital level cpt 80184 17.41 17.41 13.61 13.61 109.26 109.26 91.05 91.05 O 17.41 17.41 bcbs pos Phenobarbital level cpt 80184 17.41 17.41 13.61 13.61 109.26 109.26 91.05 91.05 O 17.41 17.41 bcbs ppo Phenobarbital level cpt 80184 17.41 17.41 13.61 13.61 109.26 109.26 91.05 91.05 O 17.41 17.41 bcbs epo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 8.28 8.28 bcbs hmo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 8.28 8.28 bcbs hmo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 8.28 8.28 bcbs pos "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 8.28 8.28 bcbs ppo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 8.28 8.28 bcbs epo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 150.25 150.25 bcbs hmo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 150.25 150.25 bcbs hmo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 150.25 150.25 bcbs pos "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 150.25 150.25 bcbs ppo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 150.25 150.25 bcbs epo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 38.68 38.68 bcbs hmo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 38.68 38.68 bcbs hmo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 38.68 38.68 bcbs pos Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 38.68 38.68 bcbs ppo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 38.68 38.68 bcbs epo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 39.93 39.93 bcbs hmo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 39.93 39.93 bcbs hmo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 39.93 39.93 bcbs pos Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 39.93 39.93 bcbs ppo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 39.93 39.93 bcbs epo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 10.31 10.31 bcbs hmo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 10.31 10.31 bcbs hmo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 10.31 10.31 bcbs pos "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 10.31 10.31 bcbs ppo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 10.31 10.31 bcbs epo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 12.63 12.63 bcbs hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 12.63 12.63 bcbs hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 12.63 12.63 bcbs pos Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 12.63 12.63 bcbs ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 12.63 12.63 bcbs epo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 36.28 36.28 bcbs hmo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 36.28 36.28 bcbs hmo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 36.28 36.28 bcbs pos Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 36.28 36.28 bcbs ppo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 36.28 36.28 bcbs epo Quantitation of therapeutic drug cpt 80299 18.72 18.72 5.39 5.39 36.89 36.89 30.74 30.74 O 5.39 5.39 bcbs hmo Quantitation of therapeutic drug cpt 80299 18.72 18.72 5.39 5.39 36.89 36.89 30.74 30.74 O 5.39 5.39 bcbs hmo Quantitation of therapeutic drug cpt 80299 18.72 18.72 5.39 5.39 36.89 36.89 30.74 30.74 O 5.39 5.39 bcbs pos Quantitation of therapeutic drug cpt 80299 18.72 18.72 5.39 5.39 36.89 36.89 30.74 30.74 O 5.39 5.39 bcbs ppo Quantitation of therapeutic drug cpt 80299 18.72 18.72 5.39 5.39 36.89 36.89 30.74 30.74 O 5.39 5.39 bcbs epo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 16.59 16.59 bcbs hmo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 16.59 16.59 bcbs hmo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 16.59 16.59 bcbs pos Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 16.59 16.59 bcbs ppo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 16.59 16.59 bcbs epo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 17.09 17.09 bcbs hmo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 17.09 17.09 bcbs hmo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 17.09 17.09 bcbs pos Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 17.09 17.09 bcbs ppo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 17.09 17.09 bcbs epo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 5.57 5.57 bcbs hmo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 5.57 5.57 bcbs hmo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 5.57 5.57 bcbs pos "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 5.57 5.57 bcbs ppo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 5.57 5.57 bcbs epo "Measurement of antibody (IgG) to allergic substance, each allergen" cpt 86001 4.38 4.38 4.38 4.38 27.64 27.64 23.03 23.03 O 4.38 4.38 bcbs hmo "Measurement of antibody (IgG) to allergic substance, each allergen" cpt 86001 4.38 4.38 4.38 4.38 27.64 27.64 23.03 23.03 O 4.38 4.38 bcbs hmo "Measurement of antibody (IgG) to allergic substance, each allergen" cpt 86001 4.38 4.38 4.38 4.38 27.64 27.64 23.03 23.03 O 4.38 4.38 bcbs pos "Measurement of antibody (IgG) to allergic substance, each allergen" cpt 86001 4.38 4.38 4.38 4.38 27.64 27.64 23.03 23.03 O 4.38 4.38 bcbs ppo "Measurement of antibody (IgG) to allergic substance, each allergen" cpt 86001 4.38 4.38 4.38 4.38 27.64 27.64 23.03 23.03 O 4.38 4.38 bcbs epo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 4.28 4.28 bcbs hmo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 4.28 4.28 bcbs hmo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 4.28 4.28 bcbs pos "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 4.28 4.28 bcbs ppo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 4.28 4.28 bcbs epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 42.96 42.96 bcbs hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 42.96 42.96 bcbs hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 42.96 42.96 bcbs pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 42.96 42.96 bcbs ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 42.96 42.96 bcbs epo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 7.02 7.02 bcbs hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 7.02 7.02 bcbs hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 7.02 7.02 bcbs pos "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 7.02 7.02 bcbs ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 7.02 7.02 bcbs epo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 5.42 5.42 bcbs hmo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 5.42 5.42 bcbs hmo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 5.42 5.42 bcbs pos "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 5.42 5.42 bcbs ppo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 5.42 5.42 bcbs epo Alcohols levels cpt 80320 33.87 33.87 33.87 33.87 287.47 287.47 239.56 239.56 O 33.87 33.87 bcbs hmo Alcohols levels cpt 80320 33.87 33.87 33.87 33.87 287.47 287.47 239.56 239.56 O 33.87 33.87 bcbs hmo Alcohols levels cpt 80320 33.87 33.87 33.87 33.87 287.47 287.47 239.56 239.56 O 33.87 33.87 bcbs pos Alcohols levels cpt 80320 33.87 33.87 33.87 33.87 287.47 287.47 239.56 239.56 O 33.87 33.87 bcbs ppo Alcohols levels cpt 80320 33.87 33.87 33.87 33.87 287.47 287.47 239.56 239.56 O 33.87 33.87 bcbs epo "Alcohols levels, 1 or 2" cpt 80321 7.63 7.63 7.63 7.63 300.92 300.92 250.77 250.77 O 7.63 7.63 bcbs hmo "Alcohols levels, 1 or 2" cpt 80321 7.63 7.63 7.63 7.63 300.92 300.92 250.77 250.77 O 7.63 7.63 bcbs hmo "Alcohols levels, 1 or 2" cpt 80321 7.63 7.63 7.63 7.63 300.92 300.92 250.77 250.77 O 7.63 7.63 bcbs pos "Alcohols levels, 1 or 2" cpt 80321 7.63 7.63 7.63 7.63 300.92 300.92 250.77 250.77 O 7.63 7.63 bcbs ppo "Alcohols levels, 1 or 2" cpt 80321 7.63 7.63 7.63 7.63 300.92 300.92 250.77 250.77 O 7.63 7.63 bcbs epo "Amphetamines levels, 1 or 2" cpt 80324 6.03 6.03 6.03 6.03 300.92 300.92 250.77 250.77 O 6.03 6.03 bcbs hmo "Amphetamines levels, 1 or 2" cpt 80324 6.03 6.03 6.03 6.03 300.92 300.92 250.77 250.77 O 6.03 6.03 bcbs hmo "Amphetamines levels, 1 or 2" cpt 80324 6.03 6.03 6.03 6.03 300.92 300.92 250.77 250.77 O 6.03 6.03 bcbs pos "Amphetamines levels, 1 or 2" cpt 80324 6.03 6.03 6.03 6.03 300.92 300.92 250.77 250.77 O 6.03 6.03 bcbs ppo "Amphetamines levels, 1 or 2" cpt 80324 6.03 6.03 6.03 6.03 300.92 300.92 250.77 250.77 O 6.03 6.03 bcbs epo "Analgesics levels, 1 or 2" cpt 80329 24.83 24.83 24.83 24.83 202.88 202.88 169.07 169.07 O 24.83 24.83 bcbs hmo "Analgesics levels, 1 or 2" cpt 80329 24.83 24.83 24.83 24.83 202.88 202.88 169.07 169.07 O 24.83 24.83 bcbs hmo "Analgesics levels, 1 or 2" cpt 80329 24.83 24.83 24.83 24.83 202.88 202.88 169.07 169.07 O 24.83 24.83 bcbs pos "Analgesics levels, 1 or 2" cpt 80329 24.83 24.83 24.83 24.83 202.88 202.88 169.07 169.07 O 24.83 24.83 bcbs ppo "Analgesics levels, 1 or 2" cpt 80329 24.83 24.83 24.83 24.83 202.88 202.88 169.07 169.07 O 24.83 24.83 bcbs epo "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" cpt 80335 6.47 6.47 6.47 6.47 300.92 300.92 250.77 250.77 O 6.47 6.47 bcbs hmo "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" cpt 80335 6.47 6.47 6.47 6.47 300.92 300.92 250.77 250.77 O 6.47 6.47 bcbs hmo "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" cpt 80335 6.47 6.47 6.47 6.47 300.92 300.92 250.77 250.77 O 6.47 6.47 bcbs pos "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" cpt 80335 6.47 6.47 6.47 6.47 300.92 300.92 250.77 250.77 O 6.47 6.47 bcbs ppo "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" cpt 80335 6.47 6.47 6.47 6.47 300.92 300.92 250.77 250.77 O 6.47 6.47 bcbs epo Barbiturates levels cpt 80345 5.32 5.32 5.32 5.32 300.92 300.92 250.77 250.77 O 5.32 5.32 bcbs hmo Barbiturates levels cpt 80345 5.32 5.32 5.32 5.32 300.92 300.92 250.77 250.77 O 5.32 5.32 bcbs hmo Barbiturates levels cpt 80345 5.32 5.32 5.32 5.32 300.92 300.92 250.77 250.77 O 5.32 5.32 bcbs pos Barbiturates levels cpt 80345 5.32 5.32 5.32 5.32 300.92 300.92 250.77 250.77 O 5.32 5.32 bcbs ppo Barbiturates levels cpt 80345 5.32 5.32 5.32 5.32 300.92 300.92 250.77 250.77 O 5.32 5.32 bcbs epo Buprenorphine level cpt 80348 7.68 7.68 7.68 7.68 300.35 300.35 250.29 250.29 O 7.68 7.68 bcbs hmo Buprenorphine level cpt 80348 7.68 7.68 7.68 7.68 300.35 300.35 250.29 250.29 O 7.68 7.68 bcbs hmo Buprenorphine level cpt 80348 7.68 7.68 7.68 7.68 300.35 300.35 250.29 250.29 O 7.68 7.68 bcbs pos Buprenorphine level cpt 80348 7.68 7.68 7.68 7.68 300.35 300.35 250.29 250.29 O 7.68 7.68 bcbs ppo Buprenorphine level cpt 80348 7.68 7.68 7.68 7.68 300.35 300.35 250.29 250.29 O 7.68 7.68 bcbs epo "Cannabinoids levels, natural" cpt 80349 3.01 3.01 3.01 3.01 128.09 128.09 106.74 106.74 O 3.01 3.01 bcbs hmo "Cannabinoids levels, natural" cpt 80349 3.01 3.01 3.01 3.01 128.09 128.09 106.74 106.74 O 3.01 3.01 bcbs hmo "Cannabinoids levels, natural" cpt 80349 3.01 3.01 3.01 3.01 128.09 128.09 106.74 106.74 O 3.01 3.01 bcbs pos "Cannabinoids levels, natural" cpt 80349 3.01 3.01 3.01 3.01 128.09 128.09 106.74 106.74 O 3.01 3.01 bcbs ppo "Cannabinoids levels, natural" cpt 80349 3.01 3.01 3.01 3.01 128.09 128.09 106.74 106.74 O 3.01 3.01 bcbs epo Fentanyl level cpt 80354 7.76 7.76 7.76 7.76 357.94 357.94 298.28 298.28 O 7.76 7.76 bcbs hmo Fentanyl level cpt 80354 7.76 7.76 7.76 7.76 357.94 357.94 298.28 298.28 O 7.76 7.76 bcbs hmo Fentanyl level cpt 80354 7.76 7.76 7.76 7.76 357.94 357.94 298.28 298.28 O 7.76 7.76 bcbs pos Fentanyl level cpt 80354 7.76 7.76 7.76 7.76 357.94 357.94 298.28 298.28 O 7.76 7.76 bcbs ppo Fentanyl level cpt 80354 7.76 7.76 7.76 7.76 357.94 357.94 298.28 298.28 O 7.76 7.76 bcbs epo Opiates levels cpt 80361 67.84 67.84 2.18 2.18 85.48 85.48 71.23 71.23 O 2.18 2.18 bcbs hmo Opiates levels cpt 80361 67.84 67.84 2.18 2.18 85.48 85.48 71.23 71.23 O 2.18 2.18 bcbs hmo Opiates levels cpt 80361 67.84 67.84 2.18 2.18 85.48 85.48 71.23 71.23 O 2.18 2.18 bcbs pos Opiates levels cpt 80361 67.84 67.84 2.18 2.18 85.48 85.48 71.23 71.23 O 2.18 2.18 bcbs ppo Opiates levels cpt 80361 67.84 67.84 2.18 2.18 85.48 85.48 71.23 71.23 O 2.18 2.18 bcbs epo Oxycodone levels cpt 80365 1.82 1.82 1.82 1.82 86.35 86.35 71.96 71.96 O 1.82 1.82 bcbs hmo Oxycodone levels cpt 80365 1.82 1.82 1.82 1.82 86.35 86.35 71.96 71.96 O 1.82 1.82 bcbs hmo Oxycodone levels cpt 80365 1.82 1.82 1.82 1.82 86.35 86.35 71.96 71.96 O 1.82 1.82 bcbs pos Oxycodone levels cpt 80365 1.82 1.82 1.82 1.82 86.35 86.35 71.96 71.96 O 1.82 1.82 bcbs ppo Oxycodone levels cpt 80365 1.82 1.82 1.82 1.82 86.35 86.35 71.96 71.96 O 1.82 1.82 bcbs epo Tramadol level cpt 80373 8.7 8.7 8.7 8.7 357.94 357.94 298.28 298.28 O 8.7 8.7 bcbs hmo Tramadol level cpt 80373 8.7 8.7 8.7 8.7 357.94 357.94 298.28 298.28 O 8.7 8.7 bcbs hmo Tramadol level cpt 80373 8.7 8.7 8.7 8.7 357.94 357.94 298.28 298.28 O 8.7 8.7 bcbs pos Tramadol level cpt 80373 8.7 8.7 8.7 8.7 357.94 357.94 298.28 298.28 O 8.7 8.7 bcbs ppo Tramadol level cpt 80373 8.7 8.7 8.7 8.7 357.94 357.94 298.28 298.28 O 8.7 8.7 bcbs epo Stereoisomer (enantiomer) drug analysis cpt 80374 4.72 4.72 4.72 4.72 300.92 300.92 250.77 250.77 O 4.72 4.72 bcbs hmo Stereoisomer (enantiomer) drug analysis cpt 80374 4.72 4.72 4.72 4.72 300.92 300.92 250.77 250.77 O 4.72 4.72 bcbs hmo Stereoisomer (enantiomer) drug analysis cpt 80374 4.72 4.72 4.72 4.72 300.92 300.92 250.77 250.77 O 4.72 4.72 bcbs pos Stereoisomer (enantiomer) drug analysis cpt 80374 4.72 4.72 4.72 4.72 300.92 300.92 250.77 250.77 O 4.72 4.72 bcbs ppo Stereoisomer (enantiomer) drug analysis cpt 80374 4.72 4.72 4.72 4.72 300.92 300.92 250.77 250.77 O 4.72 4.72 bcbs epo PCP drug level cpt 83992 11.17 11.17 11.17 11.17 300.92 300.92 250.77 250.77 O 11.17 11.17 bcbs hmo PCP drug level cpt 83992 11.17 11.17 11.17 11.17 300.92 300.92 250.77 250.77 O 11.17 11.17 bcbs hmo PCP drug level cpt 83992 11.17 11.17 11.17 11.17 300.92 300.92 250.77 250.77 O 11.17 11.17 bcbs pos PCP drug level cpt 83992 11.17 11.17 11.17 11.17 300.92 300.92 250.77 250.77 O 11.17 11.17 bcbs ppo PCP drug level cpt 83992 11.17 11.17 11.17 11.17 300.92 300.92 250.77 250.77 O 11.17 11.17 bcbs epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 35.28 35.28 bcbs hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 35.28 35.28 bcbs hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 35.28 35.28 bcbs pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 35.28 35.28 bcbs ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 35.28 35.28 bcbs epo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 8.78 8.78 bcbs hmo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 8.78 8.78 bcbs hmo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 8.78 8.78 bcbs pos Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 8.78 8.78 bcbs ppo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 8.78 8.78 bcbs epo Clotting factor VIII (VW factor) measurement cpt 85245 40.84 40.84 20.4 20.4 143.74 143.74 119.78 119.78 O 40.84 40.84 bcbs hmo Clotting factor VIII (VW factor) measurement cpt 85245 40.84 40.84 20.4 20.4 143.74 143.74 119.78 119.78 O 40.84 40.84 bcbs hmo Clotting factor VIII (VW factor) measurement cpt 85245 40.84 40.84 20.4 20.4 143.74 143.74 119.78 119.78 O 40.84 40.84 bcbs pos Clotting factor VIII (VW factor) measurement cpt 85245 40.84 40.84 20.4 20.4 143.74 143.74 119.78 119.78 O 40.84 40.84 bcbs ppo Clotting factor VIII (VW factor) measurement cpt 85245 40.84 40.84 20.4 20.4 143.74 143.74 119.78 119.78 O 40.84 40.84 bcbs epo "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" cpt 81225 254.94 254.94 254.94 254.94 874.08 874.08 728.4 728.4 O 254.94 254.94 bcbs hmo "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" cpt 81225 254.94 254.94 254.94 254.94 874.08 874.08 728.4 728.4 O 254.94 254.94 bcbs hmo "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" cpt 81225 254.94 254.94 254.94 254.94 874.08 874.08 728.4 728.4 O 254.94 254.94 bcbs pos "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" cpt 81225 254.94 254.94 254.94 254.94 874.08 874.08 728.4 728.4 O 254.94 254.94 bcbs ppo "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" cpt 81225 254.94 254.94 254.94 254.94 874.08 874.08 728.4 728.4 O 254.94 254.94 bcbs epo Blood smear interpretation by physician with written report cpt 85060 31.36 31.36 31.36 31.36 75.05 75.05 62.54 62.54 O 31.36 31.36 bcbs hmo Blood smear interpretation by physician with written report cpt 85060 31.36 31.36 31.36 31.36 75.05 75.05 62.54 62.54 O 31.36 31.36 bcbs hmo Blood smear interpretation by physician with written report cpt 85060 31.36 31.36 31.36 31.36 75.05 75.05 62.54 62.54 O 31.36 31.36 bcbs pos Blood smear interpretation by physician with written report cpt 85060 31.36 31.36 31.36 31.36 75.05 75.05 62.54 62.54 O 31.36 31.36 bcbs ppo Blood smear interpretation by physician with written report cpt 85060 31.36 31.36 31.36 31.36 75.05 75.05 62.54 62.54 O 31.36 31.36 bcbs epo Gene analysis (hemochromatosis) common variants cpt 81256 65.36 65.36 46.98 46.98 382.87 382.87 319.06 319.06 O 46.98 46.98 bcbs hmo Gene analysis (hemochromatosis) common variants cpt 81256 65.36 65.36 46.98 46.98 382.87 382.87 319.06 319.06 O 46.98 46.98 bcbs hmo Gene analysis (hemochromatosis) common variants cpt 81256 65.36 65.36 46.98 46.98 382.87 382.87 319.06 319.06 O 46.98 46.98 bcbs pos Gene analysis (hemochromatosis) common variants cpt 81256 65.36 65.36 46.98 46.98 382.87 382.87 319.06 319.06 O 46.98 46.98 bcbs ppo Gene analysis (hemochromatosis) common variants cpt 81256 65.36 65.36 46.98 46.98 382.87 382.87 319.06 319.06 O 46.98 46.98 bcbs epo Molecular pathology procedure level 1 cpt 81400 159 159 159 159 190.8 190.8 159 159 O 159 159 bcbs hmo Molecular pathology procedure level 1 cpt 81400 159 159 159 159 190.8 190.8 159 159 O 159 159 bcbs hmo Molecular pathology procedure level 1 cpt 81400 159 159 159 159 190.8 190.8 159 159 O 159 159 bcbs pos Molecular pathology procedure level 1 cpt 81400 159 159 159 159 190.8 190.8 159 159 O 159 159 bcbs ppo Molecular pathology procedure level 1 cpt 81400 159 159 159 159 190.8 190.8 159 159 O 159 159 bcbs epo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 9.87 9.87 bcbs hmo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 9.87 9.87 bcbs hmo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 9.87 9.87 bcbs pos "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 9.87 9.87 bcbs ppo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 9.87 9.87 bcbs epo "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 16.5 16.5 bcbs hmo "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 16.5 16.5 bcbs hmo "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 16.5 16.5 bcbs pos "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 16.5 16.5 bcbs ppo "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 16.5 16.5 bcbs epo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 7.82 7.82 bcbs hmo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 7.82 7.82 bcbs hmo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 7.82 7.82 bcbs pos "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 7.82 7.82 bcbs ppo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 7.82 7.82 bcbs epo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 2.27 2.27 bcbs hmo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 2.27 2.27 bcbs hmo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 2.27 2.27 bcbs pos "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 2.27 2.27 bcbs ppo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 2.27 2.27 bcbs epo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 5.52 5.52 bcbs hmo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 5.52 5.52 bcbs hmo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 5.52 5.52 bcbs pos "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 5.52 5.52 bcbs ppo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 5.52 5.52 bcbs epo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 5.38 5.38 bcbs hmo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 5.38 5.38 bcbs hmo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 5.38 5.38 bcbs pos Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 5.38 5.38 bcbs ppo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 5.38 5.38 bcbs epo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 27.35 27.35 bcbs hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 27.35 27.35 bcbs hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 27.35 27.35 bcbs pos Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 27.35 27.35 bcbs ppo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 27.35 27.35 bcbs epo Arsenic level cpt 82175 18.97 18.97 13.5 13.5 100.49 100.49 83.74 83.74 O 13.5 13.5 bcbs hmo Arsenic level cpt 82175 18.97 18.97 13.5 13.5 100.49 100.49 83.74 83.74 O 13.5 13.5 bcbs hmo Arsenic level cpt 82175 18.97 18.97 13.5 13.5 100.49 100.49 83.74 83.74 O 13.5 13.5 bcbs pos Arsenic level cpt 82175 18.97 18.97 13.5 13.5 100.49 100.49 83.74 83.74 O 13.5 13.5 bcbs ppo Arsenic level cpt 82175 18.97 18.97 13.5 13.5 100.49 100.49 83.74 83.74 O 13.5 13.5 bcbs epo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 34.65 34.65 bcbs hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 34.65 34.65 bcbs hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 34.65 34.65 bcbs pos "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 34.65 34.65 bcbs ppo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 34.65 34.65 bcbs epo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 9.99 9.99 bcbs hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 9.99 9.99 bcbs hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 9.99 9.99 bcbs pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 9.99 9.99 bcbs ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 9.99 9.99 bcbs epo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 19.19 19.19 bcbs hmo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 19.19 19.19 bcbs hmo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 19.19 19.19 bcbs pos C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 19.19 19.19 bcbs ppo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 19.19 19.19 bcbs epo "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 12.67 12.67 bcbs hmo "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 12.67 12.67 bcbs hmo "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 12.67 12.67 bcbs pos "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 12.67 12.67 bcbs ppo "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 12.67 12.67 bcbs epo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 26.27 26.27 bcbs hmo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 26.27 26.27 bcbs hmo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 26.27 26.27 bcbs pos "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 26.27 26.27 bcbs ppo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 26.27 26.27 bcbs epo Zinc level cpt 84630 11.44 11.44 10.07 10.07 82.68 82.68 68.9 68.9 O 10.07 10.07 bcbs hmo Zinc level cpt 84630 11.44 11.44 10.07 10.07 82.68 82.68 68.9 68.9 O 10.07 10.07 bcbs hmo Zinc level cpt 84630 11.44 11.44 10.07 10.07 82.68 82.68 68.9 68.9 O 10.07 10.07 bcbs pos Zinc level cpt 84630 11.44 11.44 10.07 10.07 82.68 82.68 68.9 68.9 O 10.07 10.07 bcbs ppo Zinc level cpt 84630 11.44 11.44 10.07 10.07 82.68 82.68 68.9 68.9 O 10.07 10.07 bcbs epo Vitamin measurement cpt 84591 6.57 6.57 6.57 6.57 51.18 51.18 42.65 42.65 O 6.57 6.57 bcbs hmo Vitamin measurement cpt 84591 6.57 6.57 6.57 6.57 51.18 51.18 42.65 42.65 O 6.57 6.57 bcbs hmo Vitamin measurement cpt 84591 6.57 6.57 6.57 6.57 51.18 51.18 42.65 42.65 O 6.57 6.57 bcbs pos Vitamin measurement cpt 84591 6.57 6.57 6.57 6.57 51.18 51.18 42.65 42.65 O 6.57 6.57 bcbs ppo Vitamin measurement cpt 84591 6.57 6.57 6.57 6.57 51.18 51.18 42.65 42.65 O 6.57 6.57 bcbs epo Urine vanillylmandelic acid cpt 84585 59.38 59.38 13.79 13.79 160.27 160.27 133.56 133.56 O 59.38 59.38 bcbs hmo Urine vanillylmandelic acid cpt 84585 59.38 59.38 13.79 13.79 160.27 160.27 133.56 133.56 O 59.38 59.38 bcbs hmo Urine vanillylmandelic acid cpt 84585 59.38 59.38 13.79 13.79 160.27 160.27 133.56 133.56 O 59.38 59.38 bcbs pos Urine vanillylmandelic acid cpt 84585 59.38 59.38 13.79 13.79 160.27 160.27 133.56 133.56 O 59.38 59.38 bcbs ppo Urine vanillylmandelic acid cpt 84585 59.38 59.38 13.79 13.79 160.27 160.27 133.56 133.56 O 59.38 59.38 bcbs epo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 68.52 68.52 bcbs hmo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 68.52 68.52 bcbs hmo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 68.52 68.52 bcbs pos Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 68.52 68.52 bcbs ppo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 68.52 68.52 bcbs epo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 6618.99 6618.99 bcbs hmo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 6618.99 6618.99 bcbs hmo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 6618.99 6618.99 bcbs pos multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 6618.99 6618.99 bcbs ppo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 6618.99 6618.99 bcbs epo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 9.42 9.42 bcbs hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 9.42 9.42 bcbs hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 9.42 9.42 bcbs pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 9.42 9.42 bcbs ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 9.42 9.42 bcbs epo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 8.36 8.36 bcbs hmo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 8.36 8.36 bcbs hmo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 8.36 8.36 bcbs pos "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 8.36 8.36 bcbs ppo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 8.36 8.36 bcbs epo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 50.17 50.17 bcbs hmo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 50.17 50.17 bcbs hmo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 50.17 50.17 bcbs pos "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 50.17 50.17 bcbs ppo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 50.17 50.17 bcbs epo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 10.15 10.15 bcbs hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 10.15 10.15 bcbs hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 10.15 10.15 bcbs pos Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 10.15 10.15 bcbs ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 10.15 10.15 bcbs epo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 10.84 10.84 bcbs hmo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 10.84 10.84 bcbs hmo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 10.84 10.84 bcbs pos Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 10.84 10.84 bcbs ppo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 10.84 10.84 bcbs epo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 23.89 23.89 bcbs hmo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 23.89 23.89 bcbs hmo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 23.89 23.89 bcbs pos "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 23.89 23.89 bcbs ppo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 23.89 23.89 bcbs epo Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 21.69 21.69 bcbs hmo Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 21.69 21.69 bcbs hmo Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 21.69 21.69 bcbs pos Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 21.69 21.69 bcbs ppo Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 21.69 21.69 bcbs epo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 19.91 19.91 bcbs hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 19.91 19.91 bcbs hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 19.91 19.91 bcbs pos "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 19.91 19.91 bcbs ppo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 19.91 19.91 bcbs epo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 18.44 18.44 bcbs hmo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 18.44 18.44 bcbs hmo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 18.44 18.44 bcbs pos Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 18.44 18.44 bcbs ppo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 18.44 18.44 bcbs epo "Ascorbic acid (Vitamin C) level, blood" cpt 82180 18.18 18.18 18.18 18.18 116.18 116.18 96.82 96.82 O 18.18 18.18 bcbs hmo "Ascorbic acid (Vitamin C) level, blood" cpt 82180 18.18 18.18 18.18 18.18 116.18 116.18 96.82 96.82 O 18.18 18.18 bcbs hmo "Ascorbic acid (Vitamin C) level, blood" cpt 82180 18.18 18.18 18.18 18.18 116.18 116.18 96.82 96.82 O 18.18 18.18 bcbs pos "Ascorbic acid (Vitamin C) level, blood" cpt 82180 18.18 18.18 18.18 18.18 116.18 116.18 96.82 96.82 O 18.18 18.18 bcbs ppo "Ascorbic acid (Vitamin C) level, blood" cpt 82180 18.18 18.18 18.18 18.18 116.18 116.18 96.82 96.82 O 18.18 18.18 bcbs epo Triglycerides level cpt 84478 8.51 8.51 8.51 8.51 67.42 67.42 56.18 56.18 O 8.51 8.51 bcbs hmo Triglycerides level cpt 84478 8.51 8.51 8.51 8.51 67.42 67.42 56.18 56.18 O 8.51 8.51 bcbs hmo Triglycerides level cpt 84478 8.51 8.51 8.51 8.51 67.42 67.42 56.18 56.18 O 8.51 8.51 bcbs pos Triglycerides level cpt 84478 8.51 8.51 8.51 8.51 67.42 67.42 56.18 56.18 O 8.51 8.51 bcbs ppo Triglycerides level cpt 84478 8.51 8.51 8.51 8.51 67.42 67.42 56.18 56.18 O 8.51 8.51 bcbs epo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 28.98 28.98 bcbs hmo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 28.98 28.98 bcbs hmo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 28.98 28.98 bcbs pos Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 28.98 28.98 bcbs ppo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 28.98 28.98 bcbs epo Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 10.99 10.99 bcbs hmo Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 10.99 10.99 bcbs hmo Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 10.99 10.99 bcbs pos Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 10.99 10.99 bcbs ppo Transferrin (iron binding protein) level cpt 84466 36.8 36.8 10.99 10.99 76.13 76.13 63.44 63.44 O 10.99 10.99 bcbs epo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 7.18 7.18 bcbs hmo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 7.18 7.18 bcbs hmo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 7.18 7.18 bcbs pos "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 7.18 7.18 bcbs ppo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 7.18 7.18 bcbs epo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 6.41 6.41 bcbs hmo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 6.41 6.41 bcbs hmo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 6.41 6.41 bcbs pos "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 6.41 6.41 bcbs ppo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 6.41 6.41 bcbs epo Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 12.66 12.66 bcbs hmo Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 12.66 12.66 bcbs hmo Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 12.66 12.66 bcbs pos Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 12.66 12.66 bcbs ppo Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 12.66 12.66 bcbs epo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 6.05 6.05 bcbs hmo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 6.05 6.05 bcbs hmo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 6.05 6.05 bcbs pos "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 6.05 6.05 bcbs ppo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 6.05 6.05 bcbs epo Thyroid stimulating immune globulins (thyroid related protein) level cpt 84445 60.12 60.12 45.24 45.24 146.28 146.28 121.9 121.9 O 60.12 60.12 bcbs hmo Thyroid stimulating immune globulins (thyroid related protein) level cpt 84445 60.12 60.12 45.24 45.24 146.28 146.28 121.9 121.9 O 60.12 60.12 bcbs hmo Thyroid stimulating immune globulins (thyroid related protein) level cpt 84445 60.12 60.12 45.24 45.24 146.28 146.28 121.9 121.9 O 60.12 60.12 bcbs pos Thyroid stimulating immune globulins (thyroid related protein) level cpt 84445 60.12 60.12 45.24 45.24 146.28 146.28 121.9 121.9 O 60.12 60.12 bcbs ppo Thyroid stimulating immune globulins (thyroid related protein) level cpt 84445 60.12 60.12 45.24 45.24 146.28 146.28 121.9 121.9 O 60.12 60.12 bcbs epo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 10.66 10.66 bcbs hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 10.66 10.66 bcbs hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 10.66 10.66 bcbs pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 10.66 10.66 bcbs ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 10.66 10.66 bcbs epo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 20.52 20.52 bcbs hmo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 20.52 20.52 bcbs hmo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 20.52 20.52 bcbs pos Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 20.52 20.52 bcbs ppo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 20.52 20.52 bcbs epo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 8.2 8.2 bcbs hmo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 8.2 8.2 bcbs hmo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 8.2 8.2 bcbs pos "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 8.2 8.2 bcbs ppo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 8.2 8.2 bcbs epo Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 23.54 23.54 bcbs hmo Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 23.54 23.54 bcbs hmo Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 23.54 23.54 bcbs pos Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 23.54 23.54 bcbs ppo Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 23.54 23.54 bcbs epo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 33.25 33.25 bcbs hmo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 33.25 33.25 bcbs hmo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 33.25 33.25 bcbs pos "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 33.25 33.25 bcbs ppo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 33.25 33.25 bcbs epo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 16.99 16.99 bcbs hmo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 16.99 16.99 bcbs hmo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 16.99 16.99 bcbs pos "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 16.99 16.99 bcbs ppo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 16.99 16.99 bcbs epo Somatomedin (growth factor) level cpt 84305 38.53 38.53 18.91 18.91 276.02 276.02 230.02 230.02 O 38.53 38.53 bcbs hmo Somatomedin (growth factor) level cpt 84305 38.53 38.53 18.91 18.91 276.02 276.02 230.02 230.02 O 38.53 38.53 bcbs hmo Somatomedin (growth factor) level cpt 84305 38.53 38.53 18.91 18.91 276.02 276.02 230.02 230.02 O 38.53 38.53 bcbs pos Somatomedin (growth factor) level cpt 84305 38.53 38.53 18.91 18.91 276.02 276.02 230.02 230.02 O 38.53 38.53 bcbs ppo Somatomedin (growth factor) level cpt 84305 38.53 38.53 18.91 18.91 276.02 276.02 230.02 230.02 O 38.53 38.53 bcbs epo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 21.78 21.78 bcbs hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 21.78 21.78 bcbs hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 21.78 21.78 bcbs pos Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 21.78 21.78 bcbs ppo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 21.78 21.78 bcbs epo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 21.64 21.64 bcbs hmo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 21.64 21.64 bcbs hmo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 21.64 21.64 bcbs pos Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 21.64 21.64 bcbs ppo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 21.64 21.64 bcbs epo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 18.61 18.61 bcbs hmo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 18.61 18.61 bcbs hmo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 18.61 18.61 bcbs pos "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 18.61 18.61 bcbs ppo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 18.61 18.61 bcbs epo "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 54.56 54.56 bcbs hmo "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 54.56 54.56 bcbs hmo "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 54.56 54.56 bcbs pos "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 54.56 54.56 bcbs ppo "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 54.56 54.56 bcbs epo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 11.85 11.85 bcbs hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 11.85 11.85 bcbs hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 11.85 11.85 bcbs pos "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 11.85 11.85 bcbs ppo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 11.85 11.85 bcbs epo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 11.66 11.66 bcbs hmo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 11.66 11.66 bcbs hmo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 11.66 11.66 bcbs pos "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 11.66 11.66 bcbs ppo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 11.66 11.66 bcbs epo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 10.97 10.97 bcbs hmo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 10.97 10.97 bcbs hmo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 10.97 10.97 bcbs pos "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 10.97 10.97 bcbs ppo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 10.97 10.97 bcbs epo "Calcium level, ionized" cpt 82330 48.87 48.87 13.68 13.68 99.08 99.08 82.57 82.57 O 48.87 48.87 bcbs hmo "Calcium level, ionized" cpt 82330 48.87 48.87 13.68 13.68 99.08 99.08 82.57 82.57 O 48.87 48.87 bcbs hmo "Calcium level, ionized" cpt 82330 48.87 48.87 13.68 13.68 99.08 99.08 82.57 82.57 O 48.87 48.87 bcbs pos "Calcium level, ionized" cpt 82330 48.87 48.87 13.68 13.68 99.08 99.08 82.57 82.57 O 48.87 48.87 bcbs ppo "Calcium level, ionized" cpt 82330 48.87 48.87 13.68 13.68 99.08 99.08 82.57 82.57 O 48.87 48.87 bcbs epo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 22.99 22.99 bcbs hmo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 22.99 22.99 bcbs hmo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 22.99 22.99 bcbs pos Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 22.99 22.99 bcbs ppo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 22.99 22.99 bcbs epo Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 29 29 bcbs hmo Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 29 29 bcbs hmo Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 29 29 bcbs pos Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 29 29 bcbs ppo Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 29 29 bcbs epo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 20.21 20.21 bcbs hmo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 20.21 20.21 bcbs hmo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 20.21 20.21 bcbs pos Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 20.21 20.21 bcbs ppo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 20.21 20.21 bcbs epo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 20.74 20.74 bcbs hmo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 20.74 20.74 bcbs hmo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 20.74 20.74 bcbs pos Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 20.74 20.74 bcbs ppo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 20.74 20.74 bcbs epo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 28.49 28.49 bcbs hmo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 28.49 28.49 bcbs hmo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 28.49 28.49 bcbs pos Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 28.49 28.49 bcbs ppo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 28.49 28.49 bcbs epo Carcinoembryonic antigen (CEA) protein level cpt 82378 34.13 34.13 16.86 16.86 137.4 137.4 114.5 114.5 O 34.13 34.13 bcbs hmo Carcinoembryonic antigen (CEA) protein level cpt 82378 34.13 34.13 16.86 16.86 137.4 137.4 114.5 114.5 O 34.13 34.13 bcbs hmo Carcinoembryonic antigen (CEA) protein level cpt 82378 34.13 34.13 16.86 16.86 137.4 137.4 114.5 114.5 O 34.13 34.13 bcbs pos Carcinoembryonic antigen (CEA) protein level cpt 82378 34.13 34.13 16.86 16.86 137.4 137.4 114.5 114.5 O 34.13 34.13 bcbs ppo Carcinoembryonic antigen (CEA) protein level cpt 82378 34.13 34.13 16.86 16.86 137.4 137.4 114.5 114.5 O 34.13 34.13 bcbs epo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.64 14.64 bcbs hmo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.64 14.64 bcbs hmo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.64 14.64 bcbs pos Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.64 14.64 bcbs ppo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.64 14.64 bcbs epo Catecholamines (organic nitrogen) level cpt 82384 38.12 38.12 22.46 22.46 211.15 211.15 175.96 175.96 O 38.12 38.12 bcbs hmo Catecholamines (organic nitrogen) level cpt 82384 38.12 38.12 22.46 22.46 211.15 211.15 175.96 175.96 O 38.12 38.12 bcbs hmo Catecholamines (organic nitrogen) level cpt 82384 38.12 38.12 22.46 22.46 211.15 211.15 175.96 175.96 O 38.12 38.12 bcbs pos Catecholamines (organic nitrogen) level cpt 82384 38.12 38.12 22.46 22.46 211.15 211.15 175.96 175.96 O 38.12 38.12 bcbs ppo Catecholamines (organic nitrogen) level cpt 82384 38.12 38.12 22.46 22.46 211.15 211.15 175.96 175.96 O 38.12 38.12 bcbs epo Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 16.07 16.07 bcbs hmo Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 16.07 16.07 bcbs hmo Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 16.07 16.07 bcbs pos Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 16.07 16.07 bcbs ppo Ceruloplasmin (protein) level cpt 82390 39.38 39.38 9.55 9.55 77.59 77.59 64.66 64.66 O 16.07 16.07 bcbs epo Blood potassium level cpt 84132 11.42 11.42 3.08 3.08 31.8 31.8 26.5 26.5 O 11.42 11.42 bcbs hmo Blood potassium level cpt 84132 11.42 11.42 3.08 3.08 31.8 31.8 26.5 26.5 O 11.42 11.42 bcbs hmo Blood potassium level cpt 84132 11.42 11.42 3.08 3.08 31.8 31.8 26.5 26.5 O 11.42 11.42 bcbs pos Blood potassium level cpt 84132 11.42 11.42 3.08 3.08 31.8 31.8 26.5 26.5 O 11.42 11.42 bcbs ppo Blood potassium level cpt 84132 11.42 11.42 3.08 3.08 31.8 31.8 26.5 26.5 O 11.42 11.42 bcbs epo Analysis using chemiluminescent technique (light and chemical )reaction cpt 82397 14.18 14.18 6.55 6.55 58.19 58.19 48.49 48.49 O 6.55 6.55 bcbs hmo Analysis using chemiluminescent technique (light and chemical )reaction cpt 82397 14.18 14.18 6.55 6.55 58.19 58.19 48.49 48.49 O 6.55 6.55 bcbs hmo Analysis using chemiluminescent technique (light and chemical )reaction cpt 82397 14.18 14.18 6.55 6.55 58.19 58.19 48.49 48.49 O 6.55 6.55 bcbs pos Analysis using chemiluminescent technique (light and chemical )reaction cpt 82397 14.18 14.18 6.55 6.55 58.19 58.19 48.49 48.49 O 6.55 6.55 bcbs ppo Analysis using chemiluminescent technique (light and chemical )reaction cpt 82397 14.18 14.18 6.55 6.55 58.19 58.19 48.49 48.49 O 6.55 6.55 bcbs epo Urine porphyrins (metabolism substance) measurement cpt 84120 36.78 36.78 36.78 36.78 44.14 44.14 36.78 36.78 O 36.78 36.78 bcbs hmo Urine porphyrins (metabolism substance) measurement cpt 84120 36.78 36.78 36.78 36.78 44.14 44.14 36.78 36.78 O 36.78 36.78 bcbs hmo Urine porphyrins (metabolism substance) measurement cpt 84120 36.78 36.78 36.78 36.78 44.14 44.14 36.78 36.78 O 36.78 36.78 bcbs pos Urine porphyrins (metabolism substance) measurement cpt 84120 36.78 36.78 36.78 36.78 44.14 44.14 36.78 36.78 O 36.78 36.78 bcbs ppo Urine porphyrins (metabolism substance) measurement cpt 84120 36.78 36.78 36.78 36.78 44.14 44.14 36.78 36.78 O 36.78 36.78 bcbs epo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 149.99 149.99 bcbs hmo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 149.99 149.99 bcbs hmo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 149.99 149.99 bcbs pos Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 149.99 149.99 bcbs ppo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 149.99 149.99 bcbs epo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 38.69 38.69 bcbs hmo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 38.69 38.69 bcbs hmo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 38.69 38.69 bcbs pos Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 38.69 38.69 bcbs ppo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 38.69 38.69 bcbs epo "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 35.81 35.81 bcbs hmo "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 35.81 35.81 bcbs hmo "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 35.81 35.81 bcbs pos "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 35.81 35.81 bcbs ppo "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 35.81 35.81 bcbs epo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 5.92 5.92 bcbs hmo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 5.92 5.92 bcbs hmo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 5.92 5.92 bcbs pos Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 5.92 5.92 bcbs ppo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 5.92 5.92 bcbs epo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 18.64 18.64 bcbs hmo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 18.64 18.64 bcbs hmo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 18.64 18.64 bcbs pos "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 18.64 18.64 bcbs ppo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 18.64 18.64 bcbs epo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 14.08 14.08 bcbs hmo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 14.08 14.08 bcbs hmo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 14.08 14.08 bcbs pos Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 14.08 14.08 bcbs ppo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 14.08 14.08 bcbs epo Chemical analysis using chromatography technique cpt 82542 21.43 21.43 17.69 17.69 105.58 105.58 87.98 87.98 O 17.69 17.69 bcbs hmo Chemical analysis using chromatography technique cpt 82542 21.43 21.43 17.69 17.69 105.58 105.58 87.98 87.98 O 17.69 17.69 bcbs hmo Chemical analysis using chromatography technique cpt 82542 21.43 21.43 17.69 17.69 105.58 105.58 87.98 87.98 O 17.69 17.69 bcbs pos Chemical analysis using chromatography technique cpt 82542 21.43 21.43 17.69 17.69 105.58 105.58 87.98 87.98 O 17.69 17.69 bcbs ppo Chemical analysis using chromatography technique cpt 82542 21.43 21.43 17.69 17.69 105.58 105.58 87.98 87.98 O 17.69 17.69 bcbs epo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 29.88 29.88 bcbs hmo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 29.88 29.88 bcbs hmo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 29.88 29.88 bcbs pos Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 29.88 29.88 bcbs ppo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 29.88 29.88 bcbs epo Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 16.85 16.85 bcbs hmo Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 16.85 16.85 bcbs hmo Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 16.85 16.85 bcbs pos Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 16.85 16.85 bcbs ppo Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 16.85 16.85 bcbs epo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 41.9 41.9 bcbs hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 41.9 41.9 bcbs hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 41.9 41.9 bcbs pos "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 41.9 41.9 bcbs ppo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 41.9 41.9 bcbs epo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 17.18 17.18 bcbs hmo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 17.18 17.18 bcbs hmo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 17.18 17.18 bcbs pos "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 17.18 17.18 bcbs ppo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 17.18 17.18 bcbs epo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 33.93 33.93 bcbs hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 33.93 33.93 bcbs hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 33.93 33.93 bcbs pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 33.93 33.93 bcbs ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 33.93 33.93 bcbs epo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 23.49 23.49 bcbs hmo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 23.49 23.49 bcbs hmo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 23.49 23.49 bcbs pos Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 23.49 23.49 bcbs ppo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 23.49 23.49 bcbs epo Mercury level cpt 83825 19.14 19.14 14.46 14.46 142.46 142.46 118.72 118.72 O 19.14 19.14 bcbs hmo Mercury level cpt 83825 19.14 19.14 14.46 14.46 142.46 142.46 118.72 118.72 O 19.14 19.14 bcbs hmo Mercury level cpt 83825 19.14 19.14 14.46 14.46 142.46 142.46 118.72 118.72 O 19.14 19.14 bcbs pos Mercury level cpt 83825 19.14 19.14 14.46 14.46 142.46 142.46 118.72 118.72 O 19.14 19.14 bcbs ppo Mercury level cpt 83825 19.14 19.14 14.46 14.46 142.46 142.46 118.72 118.72 O 19.14 19.14 bcbs epo non-extensive o.r. procedures unrelated to principal diagnosis without cc/mcc ms-drg 989 10770.23 10770.23 10770.23 10770.23 23596.02 23596.02 19663.35 19663.35 I 10770.23 10770.23 bcbs hmo non-extensive o.r. procedures unrelated to principal diagnosis without cc/mcc ms-drg 989 10770.23 10770.23 10770.23 10770.23 23596.02 23596.02 19663.35 19663.35 I 10770.23 10770.23 bcbs hmo non-extensive o.r. procedures unrelated to principal diagnosis without cc/mcc ms-drg 989 10770.23 10770.23 10770.23 10770.23 23596.02 23596.02 19663.35 19663.35 I 10770.23 10770.23 bcbs pos non-extensive o.r. procedures unrelated to principal diagnosis without cc/mcc ms-drg 989 10770.23 10770.23 10770.23 10770.23 23596.02 23596.02 19663.35 19663.35 I 10770.23 10770.23 bcbs ppo non-extensive o.r. procedures unrelated to principal diagnosis without cc/mcc ms-drg 989 10770.23 10770.23 10770.23 10770.23 23596.02 23596.02 19663.35 19663.35 I 10770.23 10770.23 bcbs epo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 43.72 43.72 bcbs hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 43.72 43.72 bcbs hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 43.72 43.72 bcbs pos "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 43.72 43.72 bcbs ppo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 43.72 43.72 bcbs epo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 14.63 14.63 bcbs hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 14.63 14.63 bcbs hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 14.63 14.63 bcbs pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 14.63 14.63 bcbs ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 14.63 14.63 bcbs epo Lipoprotein (A) level cpt 83695 18.46 18.46 12.74 12.74 90.31 90.31 75.26 75.26 O 18.46 18.46 bcbs hmo Lipoprotein (A) level cpt 83695 18.46 18.46 12.74 12.74 90.31 90.31 75.26 75.26 O 18.46 18.46 bcbs hmo Lipoprotein (A) level cpt 83695 18.46 18.46 12.74 12.74 90.31 90.31 75.26 75.26 O 18.46 18.46 bcbs pos Lipoprotein (A) level cpt 83695 18.46 18.46 12.74 12.74 90.31 90.31 75.26 75.26 O 18.46 18.46 bcbs ppo Lipoprotein (A) level cpt 83695 18.46 18.46 12.74 12.74 90.31 90.31 75.26 75.26 O 18.46 18.46 bcbs epo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 8.93 8.93 bcbs hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 8.93 8.93 bcbs hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 8.93 8.93 bcbs pos Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 8.93 8.93 bcbs ppo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 8.93 8.93 bcbs epo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 32 32 bcbs hmo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 32 32 bcbs hmo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 32 32 bcbs pos Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 32 32 bcbs ppo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 32 32 bcbs epo Lead level cpt 83655 12.11 12.11 10.77 10.77 64.87 64.87 54.06 54.06 O 11.45 11.45 bcbs hmo Lead level cpt 83655 12.11 12.11 10.77 10.77 64.87 64.87 54.06 54.06 O 11.45 11.45 bcbs hmo Lead level cpt 83655 12.11 12.11 10.77 10.77 64.87 64.87 54.06 54.06 O 11.45 11.45 bcbs pos Lead level cpt 83655 12.11 12.11 10.77 10.77 64.87 64.87 54.06 54.06 O 11.45 11.45 bcbs ppo Lead level cpt 83655 12.11 12.11 10.77 10.77 64.87 64.87 54.06 54.06 O 11.45 11.45 bcbs epo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 10.83 10.83 bcbs hmo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 10.83 10.83 bcbs hmo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 10.83 10.83 bcbs pos Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 10.83 10.83 bcbs ppo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 10.83 10.83 bcbs epo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 8.42 8.42 bcbs hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 8.42 8.42 bcbs hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 8.42 8.42 bcbs pos Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 8.42 8.42 bcbs ppo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 8.42 8.42 bcbs epo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 9.06 9.06 bcbs hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 9.06 9.06 bcbs hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 9.06 9.06 bcbs pos Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 9.06 9.06 bcbs ppo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 9.06 9.06 bcbs epo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 15.32 15.32 bcbs hmo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 15.32 15.32 bcbs hmo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 15.32 15.32 bcbs pos Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 15.32 15.32 bcbs ppo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 15.32 15.32 bcbs epo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 24.93 24.93 bcbs hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 24.93 24.93 bcbs hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 24.93 24.93 bcbs pos Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 24.93 24.93 bcbs ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 24.93 24.93 bcbs epo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 9.58 9.58 bcbs hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 9.58 9.58 bcbs hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 9.58 9.58 bcbs pos Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 9.58 9.58 bcbs ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 9.58 9.58 bcbs epo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.12 11.12 bcbs hmo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.12 11.12 bcbs hmo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.12 11.12 bcbs pos "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.12 11.12 bcbs ppo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.12 11.12 bcbs epo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 16.24 16.24 bcbs hmo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 16.24 16.24 bcbs hmo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 16.24 16.24 bcbs pos "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 16.24 16.24 bcbs ppo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 16.24 16.24 bcbs epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 16.3 16.3 bcbs hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 16.3 16.3 bcbs hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 16.3 16.3 bcbs pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 16.3 16.3 bcbs ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 16.3 16.3 bcbs epo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 14.89 14.89 bcbs hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 14.89 14.89 bcbs hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 14.89 14.89 bcbs pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 14.89 14.89 bcbs ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 14.89 14.89 bcbs epo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 15.73 15.73 bcbs hmo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 15.73 15.73 bcbs hmo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 15.73 15.73 bcbs pos "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 15.73 15.73 bcbs ppo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 15.73 15.73 bcbs epo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 20.9 20.9 bcbs hmo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 20.9 20.9 bcbs hmo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 20.9 20.9 bcbs pos Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 20.9 20.9 bcbs ppo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 20.9 20.9 bcbs epo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 11.15 11.15 bcbs hmo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 11.15 11.15 bcbs hmo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 11.15 11.15 bcbs pos Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 11.15 11.15 bcbs ppo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 11.15 11.15 bcbs epo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 41.86 41.86 bcbs hmo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 41.86 41.86 bcbs hmo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 41.86 41.86 bcbs pos "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 41.86 41.86 bcbs ppo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 41.86 41.86 bcbs epo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 17.78 17.78 bcbs hmo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 17.78 17.78 bcbs hmo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 17.78 17.78 bcbs pos Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 17.78 17.78 bcbs ppo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 17.78 17.78 bcbs epo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 19.44 19.44 bcbs hmo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 19.44 19.44 bcbs hmo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 19.44 19.44 bcbs pos "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 19.44 19.44 bcbs ppo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 19.44 19.44 bcbs epo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.1 7.1 bcbs hmo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.1 7.1 bcbs hmo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.1 7.1 bcbs pos Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.1 7.1 bcbs ppo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.1 7.1 bcbs epo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 51.19 51.19 bcbs hmo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 51.19 51.19 bcbs hmo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 51.19 51.19 bcbs pos Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 51.19 51.19 bcbs ppo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 51.19 51.19 bcbs epo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 14.24 14.24 bcbs hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 14.24 14.24 bcbs hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 14.24 14.24 bcbs pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 14.24 14.24 bcbs ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 14.24 14.24 bcbs epo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 22.91 22.91 bcbs hmo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 22.91 22.91 bcbs hmo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 22.91 22.91 bcbs pos Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 22.91 22.91 bcbs ppo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 22.91 22.91 bcbs epo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 9.29 9.29 bcbs hmo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 9.29 9.29 bcbs hmo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 9.29 9.29 bcbs pos "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 9.29 9.29 bcbs ppo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 9.29 9.29 bcbs epo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 31.11 31.11 bcbs hmo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 31.11 31.11 bcbs hmo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 31.11 31.11 bcbs pos Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 31.11 31.11 bcbs ppo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 31.11 31.11 bcbs epo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 22.26 22.26 bcbs hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 22.26 22.26 bcbs hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 22.26 22.26 bcbs pos "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 22.26 22.26 bcbs ppo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 22.26 22.26 bcbs epo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 6.86 6.86 bcbs hmo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 6.86 6.86 bcbs hmo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 6.86 6.86 bcbs pos Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 6.86 6.86 bcbs ppo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 6.86 6.86 bcbs epo Ethylene glycol (antifreeze) measurement cpt 82693 27.57 27.57 27.57 27.57 349.8 349.8 291.5 291.5 O 27.57 27.57 bcbs hmo Ethylene glycol (antifreeze) measurement cpt 82693 27.57 27.57 27.57 27.57 349.8 349.8 291.5 291.5 O 27.57 27.57 bcbs hmo Ethylene glycol (antifreeze) measurement cpt 82693 27.57 27.57 27.57 27.57 349.8 349.8 291.5 291.5 O 27.57 27.57 bcbs pos Ethylene glycol (antifreeze) measurement cpt 82693 27.57 27.57 27.57 27.57 349.8 349.8 291.5 291.5 O 27.57 27.57 bcbs ppo Ethylene glycol (antifreeze) measurement cpt 82693 27.57 27.57 27.57 27.57 349.8 349.8 291.5 291.5 O 27.57 27.57 bcbs epo Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 7.28 7.28 bcbs hmo Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 7.28 7.28 bcbs hmo Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 7.28 7.28 bcbs pos Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 7.28 7.28 bcbs ppo Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 7.28 7.28 bcbs epo Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 78.89 78.89 bcbs hmo Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 78.89 78.89 bcbs hmo Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 78.89 78.89 bcbs pos Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 78.89 78.89 bcbs ppo Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 78.89 78.89 bcbs epo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 29.89 29.89 bcbs hmo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 29.89 29.89 bcbs hmo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 29.89 29.89 bcbs pos Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 29.89 29.89 bcbs ppo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 29.89 29.89 bcbs epo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 14.13 14.13 bcbs hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 14.13 14.13 bcbs hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 14.13 14.13 bcbs pos Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 14.13 14.13 bcbs ppo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 14.13 14.13 bcbs epo "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" cpt 82787 8.38 8.38 8.02 8.02 24.06 24.06 20.05 20.05 O 8.38 8.38 bcbs hmo "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" cpt 82787 8.38 8.38 8.02 8.02 24.06 24.06 20.05 20.05 O 8.38 8.38 bcbs hmo "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" cpt 82787 8.38 8.38 8.02 8.02 24.06 24.06 20.05 20.05 O 8.38 8.38 bcbs pos "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" cpt 82787 8.38 8.38 8.02 8.02 24.06 24.06 20.05 20.05 O 8.38 8.38 bcbs ppo "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" cpt 82787 8.38 8.38 8.02 8.02 24.06 24.06 20.05 20.05 O 8.38 8.38 bcbs epo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 106.19 106.19 bcbs hmo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 106.19 106.19 bcbs hmo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 106.19 106.19 bcbs pos Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 106.19 106.19 bcbs ppo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 106.19 106.19 bcbs epo IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 11.05 11.05 bcbs hmo IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 11.05 11.05 bcbs hmo IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 11.05 11.05 bcbs pos IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 11.05 11.05 bcbs ppo IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 11.05 11.05 bcbs epo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 15.54 15.54 bcbs hmo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 15.54 15.54 bcbs hmo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 15.54 15.54 bcbs pos Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 15.54 15.54 bcbs ppo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 15.54 15.54 bcbs epo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 13.09 13.09 bcbs hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 13.09 13.09 bcbs hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 13.09 13.09 bcbs pos "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 13.09 13.09 bcbs ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 13.09 13.09 bcbs epo other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9633.01 9633.01 bcbs hmo other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9633.01 9633.01 bcbs hmo other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9633.01 9633.01 bcbs pos other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9633.01 9633.01 bcbs ppo other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9633.01 9633.01 bcbs epo seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 6886.91 6886.91 bcbs hmo seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 6886.91 6886.91 bcbs hmo seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 6886.91 6886.91 bcbs pos seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 6886.91 6886.91 bcbs ppo seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 6886.91 6886.91 bcbs epo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 10317.22 10317.22 bcbs hmo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 10317.22 10317.22 bcbs hmo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 10317.22 10317.22 bcbs pos complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 10317.22 10317.22 bcbs ppo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 10317.22 10317.22 bcbs epo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 6161.39 6161.39 bcbs hmo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 6161.39 6161.39 bcbs hmo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 6161.39 6161.39 bcbs pos poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 6161.39 6161.39 bcbs ppo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 6161.39 6161.39 bcbs epo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 15043.43 15043.43 bcbs hmo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 15043.43 15043.43 bcbs hmo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 15043.43 15043.43 bcbs pos poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 15043.43 15043.43 bcbs ppo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 15043.43 15043.43 bcbs epo other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 16148.43 16148.43 bcbs hmo other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 16148.43 16148.43 bcbs hmo other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 16148.43 16148.43 bcbs pos other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 16148.43 16148.43 bcbs ppo other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 16148.43 16148.43 bcbs epo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 5268.13 5268.13 bcbs hmo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 5268.13 5268.13 bcbs hmo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 5268.13 5268.13 bcbs pos "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 5268.13 5268.13 bcbs ppo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 5268.13 5268.13 bcbs epo "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 14293.05 14293.05 bcbs hmo "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 14293.05 14293.05 bcbs hmo "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 14293.05 14293.05 bcbs pos "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 14293.05 14293.05 bcbs ppo "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 14293.05 14293.05 bcbs epo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 252.56 252.56 bcbs hmo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 252.56 252.56 bcbs hmo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 252.56 252.56 bcbs pos CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 252.56 252.56 bcbs ppo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 252.56 252.56 bcbs epo organic disturbances and intellectual disability ms-drg 884 9991.17 9991.17 8103.65 8103.65 24393.3 24393.3 20327.75 20327.75 I 9991.17 9991.17 bcbs hmo organic disturbances and intellectual disability ms-drg 884 9991.17 9991.17 8103.65 8103.65 24393.3 24393.3 20327.75 20327.75 I 9991.17 9991.17 bcbs hmo organic disturbances and intellectual disability ms-drg 884 9991.17 9991.17 8103.65 8103.65 24393.3 24393.3 20327.75 20327.75 I 9991.17 9991.17 bcbs pos organic disturbances and intellectual disability ms-drg 884 9991.17 9991.17 8103.65 8103.65 24393.3 24393.3 20327.75 20327.75 I 9991.17 9991.17 bcbs ppo organic disturbances and intellectual disability ms-drg 884 9991.17 9991.17 8103.65 8103.65 24393.3 24393.3 20327.75 20327.75 I 9991.17 9991.17 bcbs epo disorders of personality and impulse control ms-drg 883 9665.06 9665.06 7955.07 7955.07 22695.91 22695.91 18913.26 18913.26 I 9665.06 9665.06 bcbs hmo disorders of personality and impulse control ms-drg 883 9665.06 9665.06 7955.07 7955.07 22695.91 22695.91 18913.26 18913.26 I 9665.06 9665.06 bcbs hmo disorders of personality and impulse control ms-drg 883 9665.06 9665.06 7955.07 7955.07 22695.91 22695.91 18913.26 18913.26 I 9665.06 9665.06 bcbs pos disorders of personality and impulse control ms-drg 883 9665.06 9665.06 7955.07 7955.07 22695.91 22695.91 18913.26 18913.26 I 9665.06 9665.06 bcbs ppo disorders of personality and impulse control ms-drg 883 9665.06 9665.06 7955.07 7955.07 22695.91 22695.91 18913.26 18913.26 I 9665.06 9665.06 bcbs epo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5854.77 5854.77 bcbs hmo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5854.77 5854.77 bcbs hmo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5854.77 5854.77 bcbs pos depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5854.77 5854.77 bcbs ppo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5854.77 5854.77 bcbs epo "X-ray of shoulder, 1 view" cpt 73020 203.52 203.52 13.25 13.25 244.22 244.22 203.52 203.52 O 105.54 105.54 bcbs hmo "X-ray of shoulder, 1 view" cpt 73020 203.52 203.52 13.25 13.25 244.22 244.22 203.52 203.52 O 105.54 105.54 bcbs hmo "X-ray of shoulder, 1 view" cpt 73020 203.52 203.52 13.25 13.25 244.22 244.22 203.52 203.52 O 105.54 105.54 bcbs pos "X-ray of shoulder, 1 view" cpt 73020 203.52 203.52 13.25 13.25 244.22 244.22 203.52 203.52 O 105.54 105.54 bcbs ppo "X-ray of shoulder, 1 view" cpt 73020 203.52 203.52 13.25 13.25 244.22 244.22 203.52 203.52 O 105.54 105.54 bcbs epo acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 6995.95 6995.95 bcbs hmo acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 6995.95 6995.95 bcbs hmo acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 6995.95 6995.95 bcbs pos acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 6995.95 6995.95 bcbs ppo acute adjustment reaction and psychosocial dysfunction ms-drg 880 6995.95 6995.95 2854.92 2854.92 20856.24 20856.24 17380.2 17380.2 I 6995.95 6995.95 bcbs epo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 216.32 216.32 bcbs hmo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 216.32 216.32 bcbs hmo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 216.32 216.32 bcbs pos Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 216.32 216.32 bcbs ppo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 216.32 216.32 bcbs epo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 8660.91 8660.91 bcbs hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 8660.91 8660.91 bcbs hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 8660.91 8660.91 bcbs pos septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 8660.91 8660.91 bcbs ppo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 8660.91 8660.91 bcbs epo signs and symptoms without mcc ms-drg 948 7102.12 7102.12 3008.27 3008.27 18472.45 18472.45 15393.71 15393.71 I 7102.12 7102.12 bcbs hmo signs and symptoms without mcc ms-drg 948 7102.12 7102.12 3008.27 3008.27 18472.45 18472.45 15393.71 15393.71 I 7102.12 7102.12 bcbs hmo signs and symptoms without mcc ms-drg 948 7102.12 7102.12 3008.27 3008.27 18472.45 18472.45 15393.71 15393.71 I 7102.12 7102.12 bcbs pos signs and symptoms without mcc ms-drg 948 7102.12 7102.12 3008.27 3008.27 18472.45 18472.45 15393.71 15393.71 I 7102.12 7102.12 bcbs ppo signs and symptoms without mcc ms-drg 948 7102.12 7102.12 3008.27 3008.27 18472.45 18472.45 15393.71 15393.71 I 7102.12 7102.12 bcbs epo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 756.88 756.88 bcbs hmo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 756.88 756.88 bcbs hmo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 756.88 756.88 bcbs pos Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 756.88 756.88 bcbs ppo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 756.88 756.88 bcbs epo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 18280.29 18280.29 bcbs hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 18280.29 18280.29 bcbs hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 18280.29 18280.29 bcbs pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 18280.29 18280.29 bcbs ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 18280.29 18280.29 bcbs epo Albumin (protein) level cpt 82040 9.85 9.85 4.95 4.95 40.44 40.44 33.7 33.7 O 9.85 9.85 bcbs hmo Albumin (protein) level cpt 82040 9.85 9.85 4.95 4.95 40.44 40.44 33.7 33.7 O 9.85 9.85 bcbs hmo Albumin (protein) level cpt 82040 9.85 9.85 4.95 4.95 40.44 40.44 33.7 33.7 O 9.85 9.85 bcbs pos Albumin (protein) level cpt 82040 9.85 9.85 4.95 4.95 40.44 40.44 33.7 33.7 O 9.85 9.85 bcbs ppo Albumin (protein) level cpt 82040 9.85 9.85 4.95 4.95 40.44 40.44 33.7 33.7 O 9.85 9.85 bcbs epo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1143.84 1143.84 bcbs hmo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1143.84 1143.84 bcbs hmo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1143.84 1143.84 bcbs pos Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1143.84 1143.84 bcbs ppo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1143.84 1143.84 bcbs epo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 82754.48 82754.48 bcbs hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 82754.48 82754.48 bcbs hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 82754.48 82754.48 bcbs pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 82754.48 82754.48 bcbs ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 82754.48 82754.48 bcbs epo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 18368.01 18368.01 bcbs hmo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 18368.01 18368.01 bcbs hmo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 18368.01 18368.01 bcbs pos postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 18368.01 18368.01 bcbs ppo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 18368.01 18368.01 bcbs epo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 19157.94 19157.94 bcbs hmo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 19157.94 19157.94 bcbs hmo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 19157.94 19157.94 bcbs pos infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 19157.94 19157.94 bcbs ppo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 19157.94 19157.94 bcbs epo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 85704.11 85704.11 bcbs hmo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 85704.11 85704.11 bcbs hmo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 85704.11 85704.11 bcbs pos infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 85704.11 85704.11 bcbs ppo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 85704.11 85704.11 bcbs epo lymphoma and non-acute leukemia with cc ms-drg 841 24430.5 24430.5 10276.4 10276.4 22126.63 22126.63 18438.86 18438.86 I 24430.5 24430.5 bcbs hmo lymphoma and non-acute leukemia with cc ms-drg 841 24430.5 24430.5 10276.4 10276.4 22126.63 22126.63 18438.86 18438.86 I 24430.5 24430.5 bcbs hmo lymphoma and non-acute leukemia with cc ms-drg 841 24430.5 24430.5 10276.4 10276.4 22126.63 22126.63 18438.86 18438.86 I 24430.5 24430.5 bcbs pos lymphoma and non-acute leukemia with cc ms-drg 841 24430.5 24430.5 10276.4 10276.4 22126.63 22126.63 18438.86 18438.86 I 24430.5 24430.5 bcbs ppo lymphoma and non-acute leukemia with cc ms-drg 841 24430.5 24430.5 10276.4 10276.4 22126.63 22126.63 18438.86 18438.86 I 24430.5 24430.5 bcbs epo lymphoma and non-acute leukemia with mcc ms-drg 840 24876.86 24876.86 16212.54 16212.54 103181.56 103181.56 85984.63 85984.63 I 16212.54 16212.54 bcbs hmo lymphoma and non-acute leukemia with mcc ms-drg 840 24876.86 24876.86 16212.54 16212.54 103181.56 103181.56 85984.63 85984.63 I 16212.54 16212.54 bcbs hmo lymphoma and non-acute leukemia with mcc ms-drg 840 24876.86 24876.86 16212.54 16212.54 103181.56 103181.56 85984.63 85984.63 I 16212.54 16212.54 bcbs pos lymphoma and non-acute leukemia with mcc ms-drg 840 24876.86 24876.86 16212.54 16212.54 103181.56 103181.56 85984.63 85984.63 I 16212.54 16212.54 bcbs ppo lymphoma and non-acute leukemia with mcc ms-drg 840 24876.86 24876.86 16212.54 16212.54 103181.56 103181.56 85984.63 85984.63 I 16212.54 16212.54 bcbs epo Drainage of abscess cpt 10060 686.2 686.2 141.39 141.39 1122.38 1122.38 935.32 935.32 O 686.2 686.2 bcbs hmo Drainage of abscess cpt 10060 686.2 686.2 141.39 141.39 1122.38 1122.38 935.32 935.32 O 686.2 686.2 bcbs hmo Drainage of abscess cpt 10060 686.2 686.2 141.39 141.39 1122.38 1122.38 935.32 935.32 O 686.2 686.2 bcbs pos Drainage of abscess cpt 10060 686.2 686.2 141.39 141.39 1122.38 1122.38 935.32 935.32 O 686.2 686.2 bcbs ppo Drainage of abscess cpt 10060 686.2 686.2 141.39 141.39 1122.38 1122.38 935.32 935.32 O 686.2 686.2 bcbs epo acute leukemia without major o.r. procedures with cc ms-drg 835 26232.54 26232.54 26232.54 26232.54 52465.08 52465.08 43720.9 43720.9 I 26232.54 26232.54 bcbs hmo acute leukemia without major o.r. procedures with cc ms-drg 835 26232.54 26232.54 26232.54 26232.54 52465.08 52465.08 43720.9 43720.9 I 26232.54 26232.54 bcbs hmo acute leukemia without major o.r. procedures with cc ms-drg 835 26232.54 26232.54 26232.54 26232.54 52465.08 52465.08 43720.9 43720.9 I 26232.54 26232.54 bcbs pos acute leukemia without major o.r. procedures with cc ms-drg 835 26232.54 26232.54 26232.54 26232.54 52465.08 52465.08 43720.9 43720.9 I 26232.54 26232.54 bcbs ppo acute leukemia without major o.r. procedures with cc ms-drg 835 26232.54 26232.54 26232.54 26232.54 52465.08 52465.08 43720.9 43720.9 I 26232.54 26232.54 bcbs epo Drainage of multiple abscess cpt 10061 561.42 561.42 278.52 278.52 13987.92 13987.92 11656.6 11656.6 O 561.42 561.42 bcbs hmo Drainage of multiple abscess cpt 10061 561.42 561.42 278.52 278.52 13987.92 13987.92 11656.6 11656.6 O 561.42 561.42 bcbs hmo Drainage of multiple abscess cpt 10061 561.42 561.42 278.52 278.52 13987.92 13987.92 11656.6 11656.6 O 561.42 561.42 bcbs pos Drainage of multiple abscess cpt 10061 561.42 561.42 278.52 278.52 13987.92 13987.92 11656.6 11656.6 O 561.42 561.42 bcbs ppo Drainage of multiple abscess cpt 10061 561.42 561.42 278.52 278.52 13987.92 13987.92 11656.6 11656.6 O 561.42 561.42 bcbs epo other antepartum diagnoses without o.r. procedures without cc/mcc ms-drg 833 4609.85 4609.85 1574.02 1574.02 9601.67 9601.67 8001.39 8001.39 I 4609.85 4609.85 bcbs hmo other antepartum diagnoses without o.r. procedures without cc/mcc ms-drg 833 4609.85 4609.85 1574.02 1574.02 9601.67 9601.67 8001.39 8001.39 I 4609.85 4609.85 bcbs hmo other antepartum diagnoses without o.r. procedures without cc/mcc ms-drg 833 4609.85 4609.85 1574.02 1574.02 9601.67 9601.67 8001.39 8001.39 I 4609.85 4609.85 bcbs pos other antepartum diagnoses without o.r. procedures without cc/mcc ms-drg 833 4609.85 4609.85 1574.02 1574.02 9601.67 9601.67 8001.39 8001.39 I 4609.85 4609.85 bcbs ppo other antepartum diagnoses without o.r. procedures without cc/mcc ms-drg 833 4609.85 4609.85 1574.02 1574.02 9601.67 9601.67 8001.39 8001.39 I 4609.85 4609.85 bcbs epo lymphoma and leukemia with major o.r. procedures without cc/mcc ms-drg 822 18012.77 18012.77 8024.86 8024.86 29988.86 29988.86 24990.72 24990.72 I 18012.77 18012.77 bcbs hmo lymphoma and leukemia with major o.r. procedures without cc/mcc ms-drg 822 18012.77 18012.77 8024.86 8024.86 29988.86 29988.86 24990.72 24990.72 I 18012.77 18012.77 bcbs hmo lymphoma and leukemia with major o.r. procedures without cc/mcc ms-drg 822 18012.77 18012.77 8024.86 8024.86 29988.86 29988.86 24990.72 24990.72 I 18012.77 18012.77 bcbs pos lymphoma and leukemia with major o.r. procedures without cc/mcc ms-drg 822 18012.77 18012.77 8024.86 8024.86 29988.86 29988.86 24990.72 24990.72 I 18012.77 18012.77 bcbs ppo lymphoma and leukemia with major o.r. procedures without cc/mcc ms-drg 822 18012.77 18012.77 8024.86 8024.86 29988.86 29988.86 24990.72 24990.72 I 18012.77 18012.77 bcbs epo other antepartum diagnoses with o.r. procedures without cc/mcc ms-drg 819 9322.89 9322.89 5314.57 5314.57 36119.1 36119.1 30099.25 30099.25 I 9322.89 9322.89 bcbs hmo other antepartum diagnoses with o.r. procedures without cc/mcc ms-drg 819 9322.89 9322.89 5314.57 5314.57 36119.1 36119.1 30099.25 30099.25 I 9322.89 9322.89 bcbs hmo other antepartum diagnoses with o.r. procedures without cc/mcc ms-drg 819 9322.89 9322.89 5314.57 5314.57 36119.1 36119.1 30099.25 30099.25 I 9322.89 9322.89 bcbs pos other antepartum diagnoses with o.r. procedures without cc/mcc ms-drg 819 9322.89 9322.89 5314.57 5314.57 36119.1 36119.1 30099.25 30099.25 I 9322.89 9322.89 bcbs ppo other antepartum diagnoses with o.r. procedures without cc/mcc ms-drg 819 9322.89 9322.89 5314.57 5314.57 36119.1 36119.1 30099.25 30099.25 I 9322.89 9322.89 bcbs epo Drainage of blood or fluid accumulation cpt 10140 5905.66 5905.66 1215.96 1215.96 17090.41 17090.41 14242.01 14242.01 O 5905.66 5905.66 bcbs hmo Drainage of blood or fluid accumulation cpt 10140 5905.66 5905.66 1215.96 1215.96 17090.41 17090.41 14242.01 14242.01 O 5905.66 5905.66 bcbs hmo Drainage of blood or fluid accumulation cpt 10140 5905.66 5905.66 1215.96 1215.96 17090.41 17090.41 14242.01 14242.01 O 5905.66 5905.66 bcbs pos Drainage of blood or fluid accumulation cpt 10140 5905.66 5905.66 1215.96 1215.96 17090.41 17090.41 14242.01 14242.01 O 5905.66 5905.66 bcbs ppo Drainage of blood or fluid accumulation cpt 10140 5905.66 5905.66 1215.96 1215.96 17090.41 17090.41 14242.01 14242.01 O 5905.66 5905.66 bcbs epo other antepartum diagnoses with o.r. procedures with cc ms-drg 818 14729.92 14729.92 3547.55 3547.55 32602.97 32602.97 27169.14 27169.14 I 14729.92 14729.92 bcbs hmo other antepartum diagnoses with o.r. procedures with cc ms-drg 818 14729.92 14729.92 3547.55 3547.55 32602.97 32602.97 27169.14 27169.14 I 14729.92 14729.92 bcbs hmo other antepartum diagnoses with o.r. procedures with cc ms-drg 818 14729.92 14729.92 3547.55 3547.55 32602.97 32602.97 27169.14 27169.14 I 14729.92 14729.92 bcbs pos other antepartum diagnoses with o.r. procedures with cc ms-drg 818 14729.92 14729.92 3547.55 3547.55 32602.97 32602.97 27169.14 27169.14 I 14729.92 14729.92 bcbs ppo other antepartum diagnoses with o.r. procedures with cc ms-drg 818 14729.92 14729.92 3547.55 3547.55 32602.97 32602.97 27169.14 27169.14 I 14729.92 14729.92 bcbs epo reticuloendothelial and immunity disorders with cc ms-drg 815 14091.76 14091.76 6896.24 6896.24 20346.83 20346.83 16955.69 16955.69 I 14091.76 14091.76 bcbs hmo reticuloendothelial and immunity disorders with cc ms-drg 815 14091.76 14091.76 6896.24 6896.24 20346.83 20346.83 16955.69 16955.69 I 14091.76 14091.76 bcbs hmo reticuloendothelial and immunity disorders with cc ms-drg 815 14091.76 14091.76 6896.24 6896.24 20346.83 20346.83 16955.69 16955.69 I 14091.76 14091.76 bcbs pos reticuloendothelial and immunity disorders with cc ms-drg 815 14091.76 14091.76 6896.24 6896.24 20346.83 20346.83 16955.69 16955.69 I 14091.76 14091.76 bcbs ppo reticuloendothelial and immunity disorders with cc ms-drg 815 14091.76 14091.76 6896.24 6896.24 20346.83 20346.83 16955.69 16955.69 I 14091.76 14091.76 bcbs epo red blood cell disorders without mcc ms-drg 812 8135.51 8135.51 3725.55 3725.55 22117.79 22117.79 18431.49 18431.49 I 8135.51 8135.51 bcbs hmo red blood cell disorders without mcc ms-drg 812 8135.51 8135.51 3725.55 3725.55 22117.79 22117.79 18431.49 18431.49 I 8135.51 8135.51 bcbs hmo red blood cell disorders without mcc ms-drg 812 8135.51 8135.51 3725.55 3725.55 22117.79 22117.79 18431.49 18431.49 I 8135.51 8135.51 bcbs pos red blood cell disorders without mcc ms-drg 812 8135.51 8135.51 3725.55 3725.55 22117.79 22117.79 18431.49 18431.49 I 8135.51 8135.51 bcbs ppo red blood cell disorders without mcc ms-drg 812 8135.51 8135.51 3725.55 3725.55 22117.79 22117.79 18431.49 18431.49 I 8135.51 8135.51 bcbs epo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 15107.34 15107.34 bcbs hmo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 15107.34 15107.34 bcbs hmo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 15107.34 15107.34 bcbs pos red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 15107.34 15107.34 bcbs ppo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 15107.34 15107.34 bcbs epo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders without cc/mcc ms-drg 810 8994.96 8994.96 5857.77 5857.77 29353.13 29353.13 24460.94 24460.94 I 8994.96 8994.96 bcbs hmo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders without cc/mcc ms-drg 810 8994.96 8994.96 5857.77 5857.77 29353.13 29353.13 24460.94 24460.94 I 8994.96 8994.96 bcbs hmo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders without cc/mcc ms-drg 810 8994.96 8994.96 5857.77 5857.77 29353.13 29353.13 24460.94 24460.94 I 8994.96 8994.96 bcbs pos major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders without cc/mcc ms-drg 810 8994.96 8994.96 5857.77 5857.77 29353.13 29353.13 24460.94 24460.94 I 8994.96 8994.96 bcbs ppo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders without cc/mcc ms-drg 810 8994.96 8994.96 5857.77 5857.77 29353.13 29353.13 24460.94 24460.94 I 8994.96 8994.96 bcbs epo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders with cc ms-drg 809 12390.44 12390.44 7998.98 7998.98 53770.55 53770.55 44808.79 44808.79 I 12390.44 12390.44 bcbs hmo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders with cc ms-drg 809 12390.44 12390.44 7998.98 7998.98 53770.55 53770.55 44808.79 44808.79 I 12390.44 12390.44 bcbs hmo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders with cc ms-drg 809 12390.44 12390.44 7998.98 7998.98 53770.55 53770.55 44808.79 44808.79 I 12390.44 12390.44 bcbs pos major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders with cc ms-drg 809 12390.44 12390.44 7998.98 7998.98 53770.55 53770.55 44808.79 44808.79 I 12390.44 12390.44 bcbs ppo major hematological and immunological diagnoses except sickle cell crisis and coagulation disorders with cc ms-drg 809 12390.44 12390.44 7998.98 7998.98 53770.55 53770.55 44808.79 44808.79 I 12390.44 12390.44 bcbs epo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 6229.59 6229.59 bcbs hmo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 6229.59 6229.59 bcbs hmo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 6229.59 6229.59 bcbs pos vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 6229.59 6229.59 bcbs ppo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 6229.59 6229.59 bcbs epo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 5438.74 5438.74 bcbs hmo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 5438.74 5438.74 bcbs hmo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 5438.74 5438.74 bcbs pos vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 5438.74 5438.74 bcbs ppo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 5438.74 5438.74 bcbs epo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 725.19 725.19 bcbs hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 725.19 725.19 bcbs hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 725.19 725.19 bcbs pos Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 725.19 725.19 bcbs ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 725.19 725.19 bcbs epo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 725.19 725.19 bcbs hmo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 725.19 725.19 bcbs hmo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 725.19 725.19 bcbs pos Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 725.19 725.19 bcbs ppo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 725.19 725.19 bcbs epo splenectomy with mcc ms-drg 799 58397.17 58397.17 58397.17 58397.17 70076.6 70076.6 58397.17 58397.17 I 58397.17 58397.17 bcbs hmo splenectomy with mcc ms-drg 799 58397.17 58397.17 58397.17 58397.17 70076.6 70076.6 58397.17 58397.17 I 58397.17 58397.17 bcbs hmo splenectomy with mcc ms-drg 799 58397.17 58397.17 58397.17 58397.17 70076.6 70076.6 58397.17 58397.17 I 58397.17 58397.17 bcbs pos splenectomy with mcc ms-drg 799 58397.17 58397.17 58397.17 58397.17 70076.6 70076.6 58397.17 58397.17 I 58397.17 58397.17 bcbs ppo splenectomy with mcc ms-drg 799 58397.17 58397.17 58397.17 58397.17 70076.6 70076.6 58397.17 58397.17 I 58397.17 58397.17 bcbs epo vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 6095.32 6095.32 bcbs hmo vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 6095.32 6095.32 bcbs hmo vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 6095.32 6095.32 bcbs pos vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 6095.32 6095.32 bcbs ppo vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 6095.32 6095.32 bcbs epo cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 7536.77 7536.77 bcbs hmo cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 7536.77 7536.77 bcbs hmo cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 7536.77 7536.77 bcbs pos cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 7536.77 7536.77 bcbs ppo cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 7536.77 7536.77 bcbs epo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 bcbs hmo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 bcbs hmo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 bcbs pos cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 bcbs ppo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 bcbs epo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 5616.54 5616.54 bcbs hmo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 5616.54 5616.54 bcbs hmo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 5616.54 5616.54 bcbs pos postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 5616.54 5616.54 bcbs ppo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 5616.54 5616.54 bcbs epo vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 9464.17 9464.17 bcbs hmo vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 9464.17 9464.17 bcbs hmo vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 9464.17 9464.17 bcbs pos vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 9464.17 9464.17 bcbs ppo vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 9464.17 9464.17 bcbs epo inflammation of the male reproductive system without mcc ms-drg 728 6665.67 6665.67 2407.15 2407.15 11957.9 11957.9 9964.92 9964.92 I 6665.67 6665.67 bcbs hmo inflammation of the male reproductive system without mcc ms-drg 728 6665.67 6665.67 2407.15 2407.15 11957.9 11957.9 9964.92 9964.92 I 6665.67 6665.67 bcbs hmo inflammation of the male reproductive system without mcc ms-drg 728 6665.67 6665.67 2407.15 2407.15 11957.9 11957.9 9964.92 9964.92 I 6665.67 6665.67 bcbs pos inflammation of the male reproductive system without mcc ms-drg 728 6665.67 6665.67 2407.15 2407.15 11957.9 11957.9 9964.92 9964.92 I 6665.67 6665.67 bcbs ppo inflammation of the male reproductive system without mcc ms-drg 728 6665.67 6665.67 2407.15 2407.15 11957.9 11957.9 9964.92 9964.92 I 6665.67 6665.67 bcbs epo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 39.6 39.6 bcbs hmo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 39.6 39.6 bcbs hmo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 39.6 39.6 bcbs pos "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 39.6 39.6 bcbs ppo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 39.6 39.6 bcbs epo major male pelvic procedures without cc/mcc ms-drg 708 12301.43 12301.43 8430.85 8430.85 57462.36 57462.36 47885.3 47885.3 I 12301.43 12301.43 bcbs hmo major male pelvic procedures without cc/mcc ms-drg 708 12301.43 12301.43 8430.85 8430.85 57462.36 57462.36 47885.3 47885.3 I 12301.43 12301.43 bcbs hmo major male pelvic procedures without cc/mcc ms-drg 708 12301.43 12301.43 8430.85 8430.85 57462.36 57462.36 47885.3 47885.3 I 12301.43 12301.43 bcbs pos major male pelvic procedures without cc/mcc ms-drg 708 12301.43 12301.43 8430.85 8430.85 57462.36 57462.36 47885.3 47885.3 I 12301.43 12301.43 bcbs ppo major male pelvic procedures without cc/mcc ms-drg 708 12301.43 12301.43 8430.85 8430.85 57462.36 57462.36 47885.3 47885.3 I 12301.43 12301.43 bcbs epo major male pelvic procedures with cc/mcc ms-drg 707 13215.8 13215.8 10639.1 10639.1 62125.99 62125.99 51771.66 51771.66 I 13215.8 13215.8 bcbs hmo major male pelvic procedures with cc/mcc ms-drg 707 13215.8 13215.8 10639.1 10639.1 62125.99 62125.99 51771.66 51771.66 I 13215.8 13215.8 bcbs hmo major male pelvic procedures with cc/mcc ms-drg 707 13215.8 13215.8 10639.1 10639.1 62125.99 62125.99 51771.66 51771.66 I 13215.8 13215.8 bcbs pos major male pelvic procedures with cc/mcc ms-drg 707 13215.8 13215.8 10639.1 10639.1 62125.99 62125.99 51771.66 51771.66 I 13215.8 13215.8 bcbs ppo major male pelvic procedures with cc/mcc ms-drg 707 13215.8 13215.8 10639.1 10639.1 62125.99 62125.99 51771.66 51771.66 I 13215.8 13215.8 bcbs epo "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2173.47 2173.47 bcbs hmo "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2173.47 2173.47 bcbs hmo "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2173.47 2173.47 bcbs pos "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2173.47 2173.47 bcbs ppo "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2173.47 2173.47 bcbs epo other kidney and urinary tract diagnoses without cc/mcc ms-drg 700 5405.71 5405.71 5149.02 5149.02 16275.34 16275.34 13562.78 13562.78 I 5405.71 5405.71 bcbs hmo other kidney and urinary tract diagnoses without cc/mcc ms-drg 700 5405.71 5405.71 5149.02 5149.02 16275.34 16275.34 13562.78 13562.78 I 5405.71 5405.71 bcbs hmo other kidney and urinary tract diagnoses without cc/mcc ms-drg 700 5405.71 5405.71 5149.02 5149.02 16275.34 16275.34 13562.78 13562.78 I 5405.71 5405.71 bcbs pos other kidney and urinary tract diagnoses without cc/mcc ms-drg 700 5405.71 5405.71 5149.02 5149.02 16275.34 16275.34 13562.78 13562.78 I 5405.71 5405.71 bcbs ppo other kidney and urinary tract diagnoses without cc/mcc ms-drg 700 5405.71 5405.71 5149.02 5149.02 16275.34 16275.34 13562.78 13562.78 I 5405.71 5405.71 bcbs epo other kidney and urinary tract diagnoses with cc ms-drg 699 7639.53 7639.53 4542.34 4542.34 24963.2 24963.2 20802.67 20802.67 I 7639.53 7639.53 bcbs hmo other kidney and urinary tract diagnoses with cc ms-drg 699 7639.53 7639.53 4542.34 4542.34 24963.2 24963.2 20802.67 20802.67 I 7639.53 7639.53 bcbs hmo other kidney and urinary tract diagnoses with cc ms-drg 699 7639.53 7639.53 4542.34 4542.34 24963.2 24963.2 20802.67 20802.67 I 7639.53 7639.53 bcbs pos other kidney and urinary tract diagnoses with cc ms-drg 699 7639.53 7639.53 4542.34 4542.34 24963.2 24963.2 20802.67 20802.67 I 7639.53 7639.53 bcbs ppo other kidney and urinary tract diagnoses with cc ms-drg 699 7639.53 7639.53 4542.34 4542.34 24963.2 24963.2 20802.67 20802.67 I 7639.53 7639.53 bcbs epo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 18781.88 18781.88 bcbs hmo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 18781.88 18781.88 bcbs hmo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 18781.88 18781.88 bcbs pos other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 18781.88 18781.88 bcbs ppo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 18781.88 18781.88 bcbs epo "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 4476.04 4476.04 bcbs hmo "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 4476.04 4476.04 bcbs hmo "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 4476.04 4476.04 bcbs pos "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 4476.04 4476.04 bcbs ppo "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 4476.04 4476.04 bcbs epo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 6820.88 6820.88 bcbs hmo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 6820.88 6820.88 bcbs hmo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 6820.88 6820.88 bcbs pos kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 6820.88 6820.88 bcbs ppo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 6820.88 6820.88 bcbs epo "Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11423 2631.83 2631.83 1215.96 1215.96 17605.97 17605.97 14671.64 14671.64 O 2631.83 2631.83 bcbs hmo "Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11423 2631.83 2631.83 1215.96 1215.96 17605.97 17605.97 14671.64 14671.64 O 2631.83 2631.83 bcbs hmo "Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11423 2631.83 2631.83 1215.96 1215.96 17605.97 17605.97 14671.64 14671.64 O 2631.83 2631.83 bcbs pos "Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11423 2631.83 2631.83 1215.96 1215.96 17605.97 17605.97 14671.64 14671.64 O 2631.83 2631.83 bcbs ppo "Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11423 2631.83 2631.83 1215.96 1215.96 17605.97 17605.97 14671.64 14671.64 O 2631.83 2631.83 bcbs epo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 10878.75 10878.75 bcbs hmo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 10878.75 10878.75 bcbs hmo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 10878.75 10878.75 bcbs pos kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 10878.75 10878.75 bcbs ppo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 10878.75 10878.75 bcbs epo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 8376.57 8376.57 bcbs hmo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 8376.57 8376.57 bcbs hmo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 8376.57 8376.57 bcbs pos renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 8376.57 8376.57 bcbs ppo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 8376.57 8376.57 bcbs epo "Removal of malignant growth (3.1 to 4 centimeters) of the trunk, arms, or legs" cpt 11604 2159.44 2159.44 681.92 681.92 15981.56 15981.56 13317.97 13317.97 O 2159.44 2159.44 bcbs hmo "Removal of malignant growth (3.1 to 4 centimeters) of the trunk, arms, or legs" cpt 11604 2159.44 2159.44 681.92 681.92 15981.56 15981.56 13317.97 13317.97 O 2159.44 2159.44 bcbs hmo "Removal of malignant growth (3.1 to 4 centimeters) of the trunk, arms, or legs" cpt 11604 2159.44 2159.44 681.92 681.92 15981.56 15981.56 13317.97 13317.97 O 2159.44 2159.44 bcbs pos "Removal of malignant growth (3.1 to 4 centimeters) of the trunk, arms, or legs" cpt 11604 2159.44 2159.44 681.92 681.92 15981.56 15981.56 13317.97 13317.97 O 2159.44 2159.44 bcbs ppo "Removal of malignant growth (3.1 to 4 centimeters) of the trunk, arms, or legs" cpt 11604 2159.44 2159.44 681.92 681.92 15981.56 15981.56 13317.97 13317.97 O 2159.44 2159.44 bcbs epo "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 5337.57 5337.57 bcbs hmo "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 5337.57 5337.57 bcbs hmo "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 5337.57 5337.57 bcbs pos "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 5337.57 5337.57 bcbs ppo "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 5337.57 5337.57 bcbs epo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 14766.63 14766.63 bcbs hmo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 14766.63 14766.63 bcbs hmo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 14766.63 14766.63 bcbs pos renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 14766.63 14766.63 bcbs ppo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 14766.63 14766.63 bcbs epo other kidney and urinary tract procedures with cc ms-drg 674 19025.41 19025.41 12967.56 12967.56 50807.44 50807.44 42339.53 42339.53 I 19025.41 19025.41 bcbs hmo other kidney and urinary tract procedures with cc ms-drg 674 19025.41 19025.41 12967.56 12967.56 50807.44 50807.44 42339.53 42339.53 I 19025.41 19025.41 bcbs hmo other kidney and urinary tract procedures with cc ms-drg 674 19025.41 19025.41 12967.56 12967.56 50807.44 50807.44 42339.53 42339.53 I 19025.41 19025.41 bcbs pos other kidney and urinary tract procedures with cc ms-drg 674 19025.41 19025.41 12967.56 12967.56 50807.44 50807.44 42339.53 42339.53 I 19025.41 19025.41 bcbs ppo other kidney and urinary tract procedures with cc ms-drg 674 19025.41 19025.41 12967.56 12967.56 50807.44 50807.44 42339.53 42339.53 I 19025.41 19025.41 bcbs epo kidney and ureter procedures for neoplasm with cc ms-drg 657 19461.2 19461.2 11797.09 11797.09 55709.35 55709.35 46424.46 46424.46 I 19461.2 19461.2 bcbs hmo kidney and ureter procedures for neoplasm with cc ms-drg 657 19461.2 19461.2 11797.09 11797.09 55709.35 55709.35 46424.46 46424.46 I 19461.2 19461.2 bcbs hmo kidney and ureter procedures for neoplasm with cc ms-drg 657 19461.2 19461.2 11797.09 11797.09 55709.35 55709.35 46424.46 46424.46 I 19461.2 19461.2 bcbs pos kidney and ureter procedures for neoplasm with cc ms-drg 657 19461.2 19461.2 11797.09 11797.09 55709.35 55709.35 46424.46 46424.46 I 19461.2 19461.2 bcbs ppo kidney and ureter procedures for neoplasm with cc ms-drg 657 19461.2 19461.2 11797.09 11797.09 55709.35 55709.35 46424.46 46424.46 I 19461.2 19461.2 bcbs epo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5622.44 5622.44 bcbs hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5622.44 5622.44 bcbs hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5622.44 5622.44 bcbs pos "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5622.44 5622.44 bcbs ppo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5622.44 5622.44 bcbs epo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 4573.79 4573.79 bcbs hmo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 4573.79 4573.79 bcbs hmo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 4573.79 4573.79 bcbs pos "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 4573.79 4573.79 bcbs ppo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 4573.79 4573.79 bcbs epo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 10946.86 10946.86 bcbs hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 10946.86 10946.86 bcbs hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 10946.86 10946.86 bcbs pos "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 10946.86 10946.86 bcbs ppo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 10946.86 10946.86 bcbs epo diabetes without cc/mcc ms-drg 639 6905 6905 2716.05 2716.05 25004.18 25004.18 20836.82 20836.82 I 6905 6905 bcbs hmo diabetes without cc/mcc ms-drg 639 6905 6905 2716.05 2716.05 25004.18 25004.18 20836.82 20836.82 I 6905 6905 bcbs hmo diabetes without cc/mcc ms-drg 639 6905 6905 2716.05 2716.05 25004.18 25004.18 20836.82 20836.82 I 6905 6905 bcbs pos diabetes without cc/mcc ms-drg 639 6905 6905 2716.05 2716.05 25004.18 25004.18 20836.82 20836.82 I 6905 6905 bcbs ppo diabetes without cc/mcc ms-drg 639 6905 6905 2716.05 2716.05 25004.18 25004.18 20836.82 20836.82 I 6905 6905 bcbs epo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6594.75 6594.75 bcbs hmo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6594.75 6594.75 bcbs hmo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6594.75 6594.75 bcbs pos diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6594.75 6594.75 bcbs ppo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6594.75 6594.75 bcbs epo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1401.49 1401.49 640.72 640.72 1251.49 1251.49 1042.91 1042.91 O 640.72 640.72 bcbs hmo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1401.49 1401.49 640.72 640.72 1251.49 1251.49 1042.91 1042.91 O 640.72 640.72 bcbs hmo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1401.49 1401.49 640.72 640.72 1251.49 1251.49 1042.91 1042.91 O 640.72 640.72 bcbs pos "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1401.49 1401.49 640.72 640.72 1251.49 1251.49 1042.91 1042.91 O 640.72 640.72 bcbs ppo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1401.49 1401.49 640.72 640.72 1251.49 1251.49 1042.91 1042.91 O 640.72 640.72 bcbs epo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 17801.06 17801.06 bcbs hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 17801.06 17801.06 bcbs hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 17801.06 17801.06 bcbs pos diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 17801.06 17801.06 bcbs ppo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 17801.06 17801.06 bcbs epo o.r. procedures for obesity without cc/mcc ms-drg 621 17948.64 17948.64 9347.86 9347.86 51584.39 51584.39 42986.99 42986.99 I 17948.64 17948.64 bcbs hmo o.r. procedures for obesity without cc/mcc ms-drg 621 17948.64 17948.64 9347.86 9347.86 51584.39 51584.39 42986.99 42986.99 I 17948.64 17948.64 bcbs hmo o.r. procedures for obesity without cc/mcc ms-drg 621 17948.64 17948.64 9347.86 9347.86 51584.39 51584.39 42986.99 42986.99 I 17948.64 17948.64 bcbs pos o.r. procedures for obesity without cc/mcc ms-drg 621 17948.64 17948.64 9347.86 9347.86 51584.39 51584.39 42986.99 42986.99 I 17948.64 17948.64 bcbs ppo o.r. procedures for obesity without cc/mcc ms-drg 621 17948.64 17948.64 9347.86 9347.86 51584.39 51584.39 42986.99 42986.99 I 17948.64 17948.64 bcbs epo "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 19091.29 19091.29 bcbs hmo "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 19091.29 19091.29 bcbs hmo "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 19091.29 19091.29 bcbs pos "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 19091.29 19091.29 bcbs ppo "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 19091.29 19091.29 bcbs epo "amputation of lower limb for endocrine, nutritional and metabolic disorders with mcc" ms-drg 616 30355.11 30355.11 21822.12 21822.12 71467.42 71467.42 59556.18 59556.18 I 30355.11 30355.11 bcbs hmo "amputation of lower limb for endocrine, nutritional and metabolic disorders with mcc" ms-drg 616 30355.11 30355.11 21822.12 21822.12 71467.42 71467.42 59556.18 59556.18 I 30355.11 30355.11 bcbs hmo "amputation of lower limb for endocrine, nutritional and metabolic disorders with mcc" ms-drg 616 30355.11 30355.11 21822.12 21822.12 71467.42 71467.42 59556.18 59556.18 I 30355.11 30355.11 bcbs pos "amputation of lower limb for endocrine, nutritional and metabolic disorders with mcc" ms-drg 616 30355.11 30355.11 21822.12 21822.12 71467.42 71467.42 59556.18 59556.18 I 30355.11 30355.11 bcbs ppo "amputation of lower limb for endocrine, nutritional and metabolic disorders with mcc" ms-drg 616 30355.11 30355.11 21822.12 21822.12 71467.42 71467.42 59556.18 59556.18 I 30355.11 30355.11 bcbs epo "trauma to the skin, subcutaneous tissue and breast with mcc" ms-drg 604 18821.82 18821.82 9430.43 9430.43 21023.42 21023.42 17519.52 17519.52 I 18821.82 18821.82 bcbs hmo "trauma to the skin, subcutaneous tissue and breast with mcc" ms-drg 604 18821.82 18821.82 9430.43 9430.43 21023.42 21023.42 17519.52 17519.52 I 18821.82 18821.82 bcbs hmo "trauma to the skin, subcutaneous tissue and breast with mcc" ms-drg 604 18821.82 18821.82 9430.43 9430.43 21023.42 21023.42 17519.52 17519.52 I 18821.82 18821.82 bcbs pos "trauma to the skin, subcutaneous tissue and breast with mcc" ms-drg 604 18821.82 18821.82 9430.43 9430.43 21023.42 21023.42 17519.52 17519.52 I 18821.82 18821.82 bcbs ppo "trauma to the skin, subcutaneous tissue and breast with mcc" ms-drg 604 18821.82 18821.82 9430.43 9430.43 21023.42 21023.42 17519.52 17519.52 I 18821.82 18821.82 bcbs epo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 1515.89 1515.89 472.89 472.89 1524.65 1524.65 1270.54 1270.54 O 472.89 472.89 bcbs hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 1515.89 1515.89 472.89 472.89 1524.65 1524.65 1270.54 1270.54 O 472.89 472.89 bcbs hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 1515.89 1515.89 472.89 472.89 1524.65 1524.65 1270.54 1270.54 O 472.89 472.89 bcbs pos "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 1515.89 1515.89 472.89 472.89 1524.65 1524.65 1270.54 1270.54 O 472.89 472.89 bcbs ppo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 1515.89 1515.89 472.89 472.89 1524.65 1524.65 1270.54 1270.54 O 472.89 472.89 bcbs epo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7559.03 7559.03 bcbs hmo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7559.03 7559.03 bcbs hmo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7559.03 7559.03 bcbs pos cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7559.03 7559.03 bcbs ppo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 7559.03 7559.03 bcbs epo cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 16664.06 16664.06 bcbs hmo cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 16664.06 16664.06 bcbs hmo cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 16664.06 16664.06 bcbs pos cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 16664.06 16664.06 bcbs ppo cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 16664.06 16664.06 bcbs epo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 640.72 640.72 640.72 640.72 4369.51 4369.51 3641.26 3641.26 O 640.72 640.72 bcbs hmo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 640.72 640.72 640.72 640.72 4369.51 4369.51 3641.26 3641.26 O 640.72 640.72 bcbs hmo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 640.72 640.72 640.72 640.72 4369.51 4369.51 3641.26 3641.26 O 640.72 640.72 bcbs pos "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 640.72 640.72 640.72 640.72 4369.51 4369.51 3641.26 3641.26 O 640.72 640.72 bcbs ppo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 640.72 640.72 640.72 640.72 4369.51 4369.51 3641.26 3641.26 O 640.72 640.72 bcbs epo "other skin, subcutaneous tissue and breast procedures without cc/mcc" ms-drg 581 9974.04 9974.04 7530.89 7530.89 30712.21 30712.21 25593.51 25593.51 I 9974.04 9974.04 bcbs hmo "other skin, subcutaneous tissue and breast procedures without cc/mcc" ms-drg 581 9974.04 9974.04 7530.89 7530.89 30712.21 30712.21 25593.51 25593.51 I 9974.04 9974.04 bcbs hmo "other skin, subcutaneous tissue and breast procedures without cc/mcc" ms-drg 581 9974.04 9974.04 7530.89 7530.89 30712.21 30712.21 25593.51 25593.51 I 9974.04 9974.04 bcbs pos "other skin, subcutaneous tissue and breast procedures without cc/mcc" ms-drg 581 9974.04 9974.04 7530.89 7530.89 30712.21 30712.21 25593.51 25593.51 I 9974.04 9974.04 bcbs ppo "other skin, subcutaneous tissue and breast procedures without cc/mcc" ms-drg 581 9974.04 9974.04 7530.89 7530.89 30712.21 30712.21 25593.51 25593.51 I 9974.04 9974.04 bcbs epo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 13853.94 13853.94 bcbs hmo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 13853.94 13853.94 bcbs hmo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 13853.94 13853.94 bcbs pos "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 13853.94 13853.94 bcbs ppo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 13853.94 13853.94 bcbs epo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 1652.17 1652.17 bcbs hmo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 1652.17 1652.17 bcbs hmo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 1652.17 1652.17 bcbs pos "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 1652.17 1652.17 bcbs ppo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 1652.17 1652.17 bcbs epo bone diseases and arthropathies without mcc ms-drg 554 8455.5 8455.5 4967.63 4967.63 18622.21 18622.21 15518.51 15518.51 I 8455.5 8455.5 bcbs hmo bone diseases and arthropathies without mcc ms-drg 554 8455.5 8455.5 4967.63 4967.63 18622.21 18622.21 15518.51 15518.51 I 8455.5 8455.5 bcbs hmo bone diseases and arthropathies without mcc ms-drg 554 8455.5 8455.5 4967.63 4967.63 18622.21 18622.21 15518.51 15518.51 I 8455.5 8455.5 bcbs pos bone diseases and arthropathies without mcc ms-drg 554 8455.5 8455.5 4967.63 4967.63 18622.21 18622.21 15518.51 15518.51 I 8455.5 8455.5 bcbs ppo bone diseases and arthropathies without mcc ms-drg 554 8455.5 8455.5 4967.63 4967.63 18622.21 18622.21 15518.51 15518.51 I 8455.5 8455.5 bcbs epo "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 2122.04 2122.04 2122.04 2122.04 4656.02 4656.02 3880.02 3880.02 O 2122.04 2122.04 bcbs hmo "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 2122.04 2122.04 2122.04 2122.04 4656.02 4656.02 3880.02 3880.02 O 2122.04 2122.04 bcbs hmo "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 2122.04 2122.04 2122.04 2122.04 4656.02 4656.02 3880.02 3880.02 O 2122.04 2122.04 bcbs pos "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 2122.04 2122.04 2122.04 2122.04 4656.02 4656.02 3880.02 3880.02 O 2122.04 2122.04 bcbs ppo "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 2122.04 2122.04 2122.04 2122.04 4656.02 4656.02 3880.02 3880.02 O 2122.04 2122.04 bcbs epo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12032 4468.85 4468.85 1196.5 1196.5 15697.86 15697.86 13081.55 13081.55 O 4468.85 4468.85 bcbs hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12032 4468.85 4468.85 1196.5 1196.5 15697.86 15697.86 13081.55 13081.55 O 4468.85 4468.85 bcbs hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12032 4468.85 4468.85 1196.5 1196.5 15697.86 15697.86 13081.55 13081.55 O 4468.85 4468.85 bcbs pos "Repair of wound (2.6 to 7.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12032 4468.85 4468.85 1196.5 1196.5 15697.86 15697.86 13081.55 13081.55 O 4468.85 4468.85 bcbs ppo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12032 4468.85 4468.85 1196.5 1196.5 15697.86 15697.86 13081.55 13081.55 O 4468.85 4468.85 bcbs epo "Repair of wound (20.1 to 30.0 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12036 4483.23 4483.23 4483.23 4483.23 35311.22 35311.22 29426.02 29426.02 O 4483.23 4483.23 bcbs hmo "Repair of wound (20.1 to 30.0 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12036 4483.23 4483.23 4483.23 4483.23 35311.22 35311.22 29426.02 29426.02 O 4483.23 4483.23 bcbs hmo "Repair of wound (20.1 to 30.0 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12036 4483.23 4483.23 4483.23 4483.23 35311.22 35311.22 29426.02 29426.02 O 4483.23 4483.23 bcbs pos "Repair of wound (20.1 to 30.0 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12036 4483.23 4483.23 4483.23 4483.23 35311.22 35311.22 29426.02 29426.02 O 4483.23 4483.23 bcbs ppo "Repair of wound (20.1 to 30.0 centimeters) of the scalp, underarms, trunk, arms, and/or legs" cpt 12036 4483.23 4483.23 4483.23 4483.23 35311.22 35311.22 29426.02 29426.02 O 4483.23 4483.23 bcbs epo bone diseases and arthropathies with mcc ms-drg 553 17378.1 17378.1 8579.22 8579.22 36360.38 36360.38 30300.32 30300.32 I 12327.66 12327.66 bcbs hmo bone diseases and arthropathies with mcc ms-drg 553 17378.1 17378.1 8579.22 8579.22 36360.38 36360.38 30300.32 30300.32 I 12327.66 12327.66 bcbs hmo bone diseases and arthropathies with mcc ms-drg 553 17378.1 17378.1 8579.22 8579.22 36360.38 36360.38 30300.32 30300.32 I 12327.66 12327.66 bcbs pos bone diseases and arthropathies with mcc ms-drg 553 17378.1 17378.1 8579.22 8579.22 36360.38 36360.38 30300.32 30300.32 I 12327.66 12327.66 bcbs ppo bone diseases and arthropathies with mcc ms-drg 553 17378.1 17378.1 8579.22 8579.22 36360.38 36360.38 30300.32 30300.32 I 12327.66 12327.66 bcbs epo medical back problems without mcc ms-drg 552 6174.92 6174.92 4114.58 4114.58 24041.95 24041.95 20034.96 20034.96 I 5986.67 5986.67 bcbs hmo medical back problems without mcc ms-drg 552 6174.92 6174.92 4114.58 4114.58 24041.95 24041.95 20034.96 20034.96 I 5986.67 5986.67 bcbs hmo medical back problems without mcc ms-drg 552 6174.92 6174.92 4114.58 4114.58 24041.95 24041.95 20034.96 20034.96 I 5986.67 5986.67 bcbs pos medical back problems without mcc ms-drg 552 6174.92 6174.92 4114.58 4114.58 24041.95 24041.95 20034.96 20034.96 I 5986.67 5986.67 bcbs ppo medical back problems without mcc ms-drg 552 6174.92 6174.92 4114.58 4114.58 24041.95 24041.95 20034.96 20034.96 I 5986.67 5986.67 bcbs epo back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 12494.82 12494.82 bcbs hmo back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 12494.82 12494.82 bcbs hmo back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 12494.82 12494.82 bcbs pos back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 12494.82 12494.82 bcbs ppo back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 12494.82 12494.82 bcbs epo soft tissue procedures without cc/mcc ms-drg 502 10743.81 10743.81 7599.45 7599.45 46045.74 46045.74 38371.45 38371.45 I 10743.81 10743.81 bcbs hmo soft tissue procedures without cc/mcc ms-drg 502 10743.81 10743.81 7599.45 7599.45 46045.74 46045.74 38371.45 38371.45 I 10743.81 10743.81 bcbs hmo soft tissue procedures without cc/mcc ms-drg 502 10743.81 10743.81 7599.45 7599.45 46045.74 46045.74 38371.45 38371.45 I 10743.81 10743.81 bcbs pos soft tissue procedures without cc/mcc ms-drg 502 10743.81 10743.81 7599.45 7599.45 46045.74 46045.74 38371.45 38371.45 I 10743.81 10743.81 bcbs ppo soft tissue procedures without cc/mcc ms-drg 502 10743.81 10743.81 7599.45 7599.45 46045.74 46045.74 38371.45 38371.45 I 10743.81 10743.81 bcbs epo "Partial thickness skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body are of infants and children)" cpt 15100 6603.11 6603.11 6603.11 6603.11 20368.04 20368.04 16973.37 16973.37 O 6603.11 6603.11 bcbs hmo "Partial thickness skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body are of infants and children)" cpt 15100 6603.11 6603.11 6603.11 6603.11 20368.04 20368.04 16973.37 16973.37 O 6603.11 6603.11 bcbs hmo "Partial thickness skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body are of infants and children)" cpt 15100 6603.11 6603.11 6603.11 6603.11 20368.04 20368.04 16973.37 16973.37 O 6603.11 6603.11 bcbs pos "Partial thickness skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body are of infants and children)" cpt 15100 6603.11 6603.11 6603.11 6603.11 20368.04 20368.04 16973.37 16973.37 O 6603.11 6603.11 bcbs ppo "Partial thickness skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body are of infants and children)" cpt 15100 6603.11 6603.11 6603.11 6603.11 20368.04 20368.04 16973.37 16973.37 O 6603.11 6603.11 bcbs epo "lower extremity and humerus procedures except hip, foot and femur with cc" ms-drg 493 17098.05 17098.05 11409.73 11409.73 65822.2 65822.2 54851.83 54851.83 I 17098.05 17098.05 bcbs hmo "lower extremity and humerus procedures except hip, foot and femur with cc" ms-drg 493 17098.05 17098.05 11409.73 11409.73 65822.2 65822.2 54851.83 54851.83 I 17098.05 17098.05 bcbs hmo "lower extremity and humerus procedures except hip, foot and femur with cc" ms-drg 493 17098.05 17098.05 11409.73 11409.73 65822.2 65822.2 54851.83 54851.83 I 17098.05 17098.05 bcbs pos "lower extremity and humerus procedures except hip, foot and femur with cc" ms-drg 493 17098.05 17098.05 11409.73 11409.73 65822.2 65822.2 54851.83 54851.83 I 17098.05 17098.05 bcbs ppo "lower extremity and humerus procedures except hip, foot and femur with cc" ms-drg 493 17098.05 17098.05 11409.73 11409.73 65822.2 65822.2 54851.83 54851.83 I 17098.05 17098.05 bcbs epo knee procedures without principal diagnosis of infection with cc/mcc ms-drg 488 19799.11 19799.11 19799.11 19799.11 82344.42 82344.42 68620.35 68620.35 I 19799.11 19799.11 bcbs hmo knee procedures without principal diagnosis of infection with cc/mcc ms-drg 488 19799.11 19799.11 19799.11 19799.11 82344.42 82344.42 68620.35 68620.35 I 19799.11 19799.11 bcbs hmo knee procedures without principal diagnosis of infection with cc/mcc ms-drg 488 19799.11 19799.11 19799.11 19799.11 82344.42 82344.42 68620.35 68620.35 I 19799.11 19799.11 bcbs pos knee procedures without principal diagnosis of infection with cc/mcc ms-drg 488 19799.11 19799.11 19799.11 19799.11 82344.42 82344.42 68620.35 68620.35 I 19799.11 19799.11 bcbs ppo knee procedures without principal diagnosis of infection with cc/mcc ms-drg 488 19799.11 19799.11 19799.11 19799.11 82344.42 82344.42 68620.35 68620.35 I 19799.11 19799.11 bcbs epo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs (first 100 sq cm or 1% body area of infants and children)" cpt 15273 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs hmo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs (first 100 sq cm or 1% body area of infants and children)" cpt 15273 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs hmo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs (first 100 sq cm or 1% body area of infants and children)" cpt 15273 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs pos "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs (first 100 sq cm or 1% body area of infants and children)" cpt 15273 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs ppo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs (first 100 sq cm or 1% body area of infants and children)" cpt 15273 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs epo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs" cpt 15274 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs hmo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs" cpt 15274 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs hmo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs" cpt 15274 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs pos "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs" cpt 15274 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs ppo "Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs" cpt 15274 2485.7 2485.7 2485.7 2485.7 29471.2 29471.2 24559.33 24559.33 O 2485.7 2485.7 bcbs epo knee procedures with principal diagnosis of infection without cc/mcc ms-drg 487 19088.23 19088.23 9332 9332 41727.58 41727.58 34772.98 34772.98 I 19088.23 19088.23 bcbs hmo knee procedures with principal diagnosis of infection without cc/mcc ms-drg 487 19088.23 19088.23 9332 9332 41727.58 41727.58 34772.98 34772.98 I 19088.23 19088.23 bcbs hmo knee procedures with principal diagnosis of infection without cc/mcc ms-drg 487 19088.23 19088.23 9332 9332 41727.58 41727.58 34772.98 34772.98 I 19088.23 19088.23 bcbs pos knee procedures with principal diagnosis of infection without cc/mcc ms-drg 487 19088.23 19088.23 9332 9332 41727.58 41727.58 34772.98 34772.98 I 19088.23 19088.23 bcbs ppo knee procedures with principal diagnosis of infection without cc/mcc ms-drg 487 19088.23 19088.23 9332 9332 41727.58 41727.58 34772.98 34772.98 I 19088.23 19088.23 bcbs epo knee procedures with principal diagnosis of infection with mcc ms-drg 485 44864.13 44864.13 44864.13 44864.13 141650.32 141650.32 118041.93 118041.93 I 44864.13 44864.13 bcbs hmo knee procedures with principal diagnosis of infection with mcc ms-drg 485 44864.13 44864.13 44864.13 44864.13 141650.32 141650.32 118041.93 118041.93 I 44864.13 44864.13 bcbs hmo knee procedures with principal diagnosis of infection with mcc ms-drg 485 44864.13 44864.13 44864.13 44864.13 141650.32 141650.32 118041.93 118041.93 I 44864.13 44864.13 bcbs pos knee procedures with principal diagnosis of infection with mcc ms-drg 485 44864.13 44864.13 44864.13 44864.13 141650.32 141650.32 118041.93 118041.93 I 44864.13 44864.13 bcbs ppo knee procedures with principal diagnosis of infection with mcc ms-drg 485 44864.13 44864.13 44864.13 44864.13 141650.32 141650.32 118041.93 118041.93 I 44864.13 44864.13 bcbs epo hip and femur procedures except major joint without cc/mcc ms-drg 482 18778.5 18778.5 9099.73 9099.73 55806.76 55806.76 46505.63 46505.63 I 18778.5 18778.5 bcbs hmo hip and femur procedures except major joint without cc/mcc ms-drg 482 18778.5 18778.5 9099.73 9099.73 55806.76 55806.76 46505.63 46505.63 I 18778.5 18778.5 bcbs hmo hip and femur procedures except major joint without cc/mcc ms-drg 482 18778.5 18778.5 9099.73 9099.73 55806.76 55806.76 46505.63 46505.63 I 18778.5 18778.5 bcbs pos hip and femur procedures except major joint without cc/mcc ms-drg 482 18778.5 18778.5 9099.73 9099.73 55806.76 55806.76 46505.63 46505.63 I 18778.5 18778.5 bcbs ppo hip and femur procedures except major joint without cc/mcc ms-drg 482 18778.5 18778.5 9099.73 9099.73 55806.76 55806.76 46505.63 46505.63 I 18778.5 18778.5 bcbs epo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 22569.55 22569.55 bcbs hmo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 22569.55 22569.55 bcbs hmo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 22569.55 22569.55 bcbs pos hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 22569.55 22569.55 bcbs ppo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 22569.55 22569.55 bcbs epo Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 4127.82 4127.82 bcbs hmo Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 4127.82 4127.82 bcbs hmo Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 4127.82 4127.82 bcbs pos Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 4127.82 4127.82 bcbs ppo Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 4127.82 4127.82 bcbs epo disorders of the biliary tract without cc/mcc ms-drg 446 4281.93 4281.93 626.37 626.37 12293.78 12293.78 10244.82 10244.82 I 2148.22 2148.22 bcbs hmo disorders of the biliary tract without cc/mcc ms-drg 446 4281.93 4281.93 626.37 626.37 12293.78 12293.78 10244.82 10244.82 I 2148.22 2148.22 bcbs hmo disorders of the biliary tract without cc/mcc ms-drg 446 4281.93 4281.93 626.37 626.37 12293.78 12293.78 10244.82 10244.82 I 2148.22 2148.22 bcbs pos disorders of the biliary tract without cc/mcc ms-drg 446 4281.93 4281.93 626.37 626.37 12293.78 12293.78 10244.82 10244.82 I 2148.22 2148.22 bcbs ppo disorders of the biliary tract without cc/mcc ms-drg 446 4281.93 4281.93 626.37 626.37 12293.78 12293.78 10244.82 10244.82 I 2148.22 2148.22 bcbs epo disorders of the biliary tract with cc ms-drg 445 8690.18 8690.18 5165.72 5165.72 22817.4 22817.4 19014.5 19014.5 I 8690.18 8690.18 bcbs hmo disorders of the biliary tract with cc ms-drg 445 8690.18 8690.18 5165.72 5165.72 22817.4 22817.4 19014.5 19014.5 I 8690.18 8690.18 bcbs hmo disorders of the biliary tract with cc ms-drg 445 8690.18 8690.18 5165.72 5165.72 22817.4 22817.4 19014.5 19014.5 I 8690.18 8690.18 bcbs pos disorders of the biliary tract with cc ms-drg 445 8690.18 8690.18 5165.72 5165.72 22817.4 22817.4 19014.5 19014.5 I 8690.18 8690.18 bcbs ppo disorders of the biliary tract with cc ms-drg 445 8690.18 8690.18 5165.72 5165.72 22817.4 22817.4 19014.5 19014.5 I 8690.18 8690.18 bcbs epo "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without cc/mcc" ms-drg 443 8609.76 8609.76 3148.67 3148.67 12770.82 12770.82 10642.35 10642.35 I 8609.76 8609.76 bcbs hmo "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without cc/mcc" ms-drg 443 8609.76 8609.76 3148.67 3148.67 12770.82 12770.82 10642.35 10642.35 I 8609.76 8609.76 bcbs hmo "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without cc/mcc" ms-drg 443 8609.76 8609.76 3148.67 3148.67 12770.82 12770.82 10642.35 10642.35 I 8609.76 8609.76 bcbs pos "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without cc/mcc" ms-drg 443 8609.76 8609.76 3148.67 3148.67 12770.82 12770.82 10642.35 10642.35 I 8609.76 8609.76 bcbs ppo "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without cc/mcc" ms-drg 443 8609.76 8609.76 3148.67 3148.67 12770.82 12770.82 10642.35 10642.35 I 8609.76 8609.76 bcbs epo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 11912.5 11912.5 bcbs hmo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 11912.5 11912.5 bcbs hmo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 11912.5 11912.5 bcbs pos disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 11912.5 11912.5 bcbs ppo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 11912.5 11912.5 bcbs epo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 4127.82 4127.82 bcbs hmo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 4127.82 4127.82 bcbs hmo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 4127.82 4127.82 bcbs pos "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 4127.82 4127.82 bcbs ppo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 4127.82 4127.82 bcbs epo disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 25700.17 25700.17 bcbs hmo disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 25700.17 25700.17 bcbs hmo disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 25700.17 25700.17 bcbs pos disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 25700.17 25700.17 bcbs ppo disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 25700.17 25700.17 bcbs epo "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 4003.45 4003.45 bcbs hmo "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 4003.45 4003.45 bcbs hmo "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 4003.45 4003.45 bcbs pos "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 4003.45 4003.45 bcbs ppo "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 4003.45 4003.45 bcbs epo malignancy of hepatobiliary system or pancreas with cc ms-drg 436 13157.45 13157.45 6996.06 6996.06 33590.44 33590.44 27992.03 27992.03 I 13157.45 13157.45 bcbs hmo malignancy of hepatobiliary system or pancreas with cc ms-drg 436 13157.45 13157.45 6996.06 6996.06 33590.44 33590.44 27992.03 27992.03 I 13157.45 13157.45 bcbs hmo malignancy of hepatobiliary system or pancreas with cc ms-drg 436 13157.45 13157.45 6996.06 6996.06 33590.44 33590.44 27992.03 27992.03 I 13157.45 13157.45 bcbs pos malignancy of hepatobiliary system or pancreas with cc ms-drg 436 13157.45 13157.45 6996.06 6996.06 33590.44 33590.44 27992.03 27992.03 I 13157.45 13157.45 bcbs ppo malignancy of hepatobiliary system or pancreas with cc ms-drg 436 13157.45 13157.45 6996.06 6996.06 33590.44 33590.44 27992.03 27992.03 I 13157.45 13157.45 bcbs epo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 10629.2 10629.2 bcbs hmo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 10629.2 10629.2 bcbs hmo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 10629.2 10629.2 bcbs pos cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 10629.2 10629.2 bcbs ppo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 10629.2 10629.2 bcbs epo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 9763.9 9763.9 bcbs hmo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 9763.9 9763.9 bcbs hmo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 9763.9 9763.9 bcbs pos laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 9763.9 9763.9 bcbs ppo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 9763.9 9763.9 bcbs epo laparoscopic cholecystectomy without c.d.e. with cc ms-drg 418 12197.9 12197.9 5638.44 5638.44 46278.29 46278.29 38565.24 38565.24 I 12197.9 12197.9 bcbs hmo laparoscopic cholecystectomy without c.d.e. with cc ms-drg 418 12197.9 12197.9 5638.44 5638.44 46278.29 46278.29 38565.24 38565.24 I 12197.9 12197.9 bcbs hmo laparoscopic cholecystectomy without c.d.e. with cc ms-drg 418 12197.9 12197.9 5638.44 5638.44 46278.29 46278.29 38565.24 38565.24 I 12197.9 12197.9 bcbs pos laparoscopic cholecystectomy without c.d.e. with cc ms-drg 418 12197.9 12197.9 5638.44 5638.44 46278.29 46278.29 38565.24 38565.24 I 12197.9 12197.9 bcbs ppo laparoscopic cholecystectomy without c.d.e. with cc ms-drg 418 12197.9 12197.9 5638.44 5638.44 46278.29 46278.29 38565.24 38565.24 I 12197.9 12197.9 bcbs epo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 8915.14 8915.14 bcbs hmo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 8915.14 8915.14 bcbs hmo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 8915.14 8915.14 bcbs pos Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 8915.14 8915.14 bcbs ppo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 8915.14 8915.14 bcbs epo cholecystectomy except by laparoscope without c.d.e. with cc ms-drg 415 19326.82 19326.82 12873.6 12873.6 68989.45 68989.45 57491.21 57491.21 I 19326.82 19326.82 bcbs hmo cholecystectomy except by laparoscope without c.d.e. with cc ms-drg 415 19326.82 19326.82 12873.6 12873.6 68989.45 68989.45 57491.21 57491.21 I 19326.82 19326.82 bcbs hmo cholecystectomy except by laparoscope without c.d.e. with cc ms-drg 415 19326.82 19326.82 12873.6 12873.6 68989.45 68989.45 57491.21 57491.21 I 19326.82 19326.82 bcbs pos cholecystectomy except by laparoscope without c.d.e. with cc ms-drg 415 19326.82 19326.82 12873.6 12873.6 68989.45 68989.45 57491.21 57491.21 I 19326.82 19326.82 bcbs ppo cholecystectomy except by laparoscope without c.d.e. with cc ms-drg 415 19326.82 19326.82 12873.6 12873.6 68989.45 68989.45 57491.21 57491.21 I 19326.82 19326.82 bcbs epo other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 6014.04 6014.04 bcbs hmo other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 6014.04 6014.04 bcbs hmo other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 6014.04 6014.04 bcbs pos other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 6014.04 6014.04 bcbs ppo other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 6014.04 6014.04 bcbs epo other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 8388.74 8388.74 bcbs hmo other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 8388.74 8388.74 bcbs hmo other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 8388.74 8388.74 bcbs pos other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 8388.74 8388.74 bcbs ppo other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 8388.74 8388.74 bcbs epo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 6171.29 6171.29 bcbs hmo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 6171.29 6171.29 bcbs hmo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 6171.29 6171.29 bcbs pos "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 6171.29 6171.29 bcbs ppo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 6171.29 6171.29 bcbs epo "Insertion of breast prosthesis at time of breast repositioning, removal or reconstruction" cpt 19340 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs hmo "Insertion of breast prosthesis at time of breast repositioning, removal or reconstruction" cpt 19340 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs hmo "Insertion of breast prosthesis at time of breast repositioning, removal or reconstruction" cpt 19340 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs pos "Insertion of breast prosthesis at time of breast repositioning, removal or reconstruction" cpt 19340 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs ppo "Insertion of breast prosthesis at time of breast repositioning, removal or reconstruction" cpt 19340 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs epo Removal of capsule surrounding breast cpt 19371 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs hmo Removal of capsule surrounding breast cpt 19371 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs hmo Removal of capsule surrounding breast cpt 19371 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs pos Removal of capsule surrounding breast cpt 19371 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs ppo Removal of capsule surrounding breast cpt 19371 5905.66 5905.66 5905.66 5905.66 25535.18 25535.18 21279.32 21279.32 O 5905.66 5905.66 bcbs epo Injections of tendon attachment to bone cpt 20551 16365.34 16365.34 329.32 329.32 641.84 641.84 534.87 534.87 O 16365.34 16365.34 bcbs hmo Injections of tendon attachment to bone cpt 20551 16365.34 16365.34 329.32 329.32 641.84 641.84 534.87 534.87 O 16365.34 16365.34 bcbs hmo Injections of tendon attachment to bone cpt 20551 16365.34 16365.34 329.32 329.32 641.84 641.84 534.87 534.87 O 16365.34 16365.34 bcbs pos Injections of tendon attachment to bone cpt 20551 16365.34 16365.34 329.32 329.32 641.84 641.84 534.87 534.87 O 16365.34 16365.34 bcbs ppo Injections of tendon attachment to bone cpt 20551 16365.34 16365.34 329.32 329.32 641.84 641.84 534.87 534.87 O 16365.34 16365.34 bcbs epo "esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc" ms-drg 391 8351.98 8351.98 6959.33 6959.33 31444.44 31444.44 26203.7 26203.7 I 8351.98 8351.98 bcbs hmo "esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc" ms-drg 391 8351.98 8351.98 6959.33 6959.33 31444.44 31444.44 26203.7 26203.7 I 8351.98 8351.98 bcbs hmo "esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc" ms-drg 391 8351.98 8351.98 6959.33 6959.33 31444.44 31444.44 26203.7 26203.7 I 8351.98 8351.98 bcbs pos "esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc" ms-drg 391 8351.98 8351.98 6959.33 6959.33 31444.44 31444.44 26203.7 26203.7 I 8351.98 8351.98 bcbs ppo "esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc" ms-drg 391 8351.98 8351.98 6959.33 6959.33 31444.44 31444.44 26203.7 26203.7 I 8351.98 8351.98 bcbs epo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 6339.29 6339.29 bcbs hmo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 6339.29 6339.29 bcbs hmo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 6339.29 6339.29 bcbs pos gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 6339.29 6339.29 bcbs ppo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 6339.29 6339.29 bcbs epo inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 11750.65 11750.65 bcbs hmo inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 11750.65 11750.65 bcbs hmo inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 11750.65 11750.65 bcbs pos inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 11750.65 11750.65 bcbs ppo inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 11750.65 11750.65 bcbs epo inflammatory bowel disease with mcc ms-drg 385 23283.56 23283.56 10201.78 10201.78 42057.36 42057.36 35047.8 35047.8 I 23283.56 23283.56 bcbs hmo inflammatory bowel disease with mcc ms-drg 385 23283.56 23283.56 10201.78 10201.78 42057.36 42057.36 35047.8 35047.8 I 23283.56 23283.56 bcbs hmo inflammatory bowel disease with mcc ms-drg 385 23283.56 23283.56 10201.78 10201.78 42057.36 42057.36 35047.8 35047.8 I 23283.56 23283.56 bcbs pos inflammatory bowel disease with mcc ms-drg 385 23283.56 23283.56 10201.78 10201.78 42057.36 42057.36 35047.8 35047.8 I 23283.56 23283.56 bcbs ppo inflammatory bowel disease with mcc ms-drg 385 23283.56 23283.56 10201.78 10201.78 42057.36 42057.36 35047.8 35047.8 I 23283.56 23283.56 bcbs epo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 877.03 877.03 bcbs hmo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 877.03 877.03 bcbs hmo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 877.03 877.03 bcbs pos Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 877.03 877.03 bcbs ppo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 877.03 877.03 bcbs epo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 8605.42 8605.42 bcbs hmo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 8605.42 8605.42 bcbs hmo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 8605.42 8605.42 bcbs pos gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 8605.42 8605.42 bcbs ppo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 8605.42 8605.42 bcbs epo Aspiration and/or injection of major joint or joint capsule with recording and reporting using ultrasound guidance cpt 20611 1560.4 1560.4 329.25 329.25 1023.7 1023.7 853.08 853.08 O 1560.4 1560.4 bcbs hmo Aspiration and/or injection of major joint or joint capsule with recording and reporting using ultrasound guidance cpt 20611 1560.4 1560.4 329.25 329.25 1023.7 1023.7 853.08 853.08 O 1560.4 1560.4 bcbs hmo Aspiration and/or injection of major joint or joint capsule with recording and reporting using ultrasound guidance cpt 20611 1560.4 1560.4 329.25 329.25 1023.7 1023.7 853.08 853.08 O 1560.4 1560.4 bcbs pos Aspiration and/or injection of major joint or joint capsule with recording and reporting using ultrasound guidance cpt 20611 1560.4 1560.4 329.25 329.25 1023.7 1023.7 853.08 853.08 O 1560.4 1560.4 bcbs ppo Aspiration and/or injection of major joint or joint capsule with recording and reporting using ultrasound guidance cpt 20611 1560.4 1560.4 329.25 329.25 1023.7 1023.7 853.08 853.08 O 1560.4 1560.4 bcbs epo Aspiration and injection treatment of bone cyst cpt 20615 1290.38 1290.38 1290.38 1290.38 1548.46 1548.46 1290.38 1290.38 O 1290.38 1290.38 bcbs hmo Aspiration and injection treatment of bone cyst cpt 20615 1290.38 1290.38 1290.38 1290.38 1548.46 1548.46 1290.38 1290.38 O 1290.38 1290.38 bcbs hmo Aspiration and injection treatment of bone cyst cpt 20615 1290.38 1290.38 1290.38 1290.38 1548.46 1548.46 1290.38 1290.38 O 1290.38 1290.38 bcbs pos Aspiration and injection treatment of bone cyst cpt 20615 1290.38 1290.38 1290.38 1290.38 1548.46 1548.46 1290.38 1290.38 O 1290.38 1290.38 bcbs ppo Aspiration and injection treatment of bone cyst cpt 20615 1290.38 1290.38 1290.38 1290.38 1548.46 1548.46 1290.38 1290.38 O 1290.38 1290.38 bcbs epo Removal of deep bone implant cpt 20680 5259.68 5259.68 1627.49 1627.49 19506.22 19506.22 16255.18 16255.18 O 5259.68 5259.68 bcbs hmo Removal of deep bone implant cpt 20680 5259.68 5259.68 1627.49 1627.49 19506.22 19506.22 16255.18 16255.18 O 5259.68 5259.68 bcbs hmo Removal of deep bone implant cpt 20680 5259.68 5259.68 1627.49 1627.49 19506.22 19506.22 16255.18 16255.18 O 5259.68 5259.68 bcbs pos Removal of deep bone implant cpt 20680 5259.68 5259.68 1627.49 1627.49 19506.22 19506.22 16255.18 16255.18 O 5259.68 5259.68 bcbs ppo Removal of deep bone implant cpt 20680 5259.68 5259.68 1627.49 1627.49 19506.22 19506.22 16255.18 16255.18 O 5259.68 5259.68 bcbs epo gastrointestinal hemorrhage with mcc ms-drg 377 17273.54 17273.54 7149.07 7149.07 36153.05 36153.05 30127.54 30127.54 I 17273.54 17273.54 bcbs hmo gastrointestinal hemorrhage with mcc ms-drg 377 17273.54 17273.54 7149.07 7149.07 36153.05 36153.05 30127.54 30127.54 I 17273.54 17273.54 bcbs hmo gastrointestinal hemorrhage with mcc ms-drg 377 17273.54 17273.54 7149.07 7149.07 36153.05 36153.05 30127.54 30127.54 I 17273.54 17273.54 bcbs pos gastrointestinal hemorrhage with mcc ms-drg 377 17273.54 17273.54 7149.07 7149.07 36153.05 36153.05 30127.54 30127.54 I 17273.54 17273.54 bcbs ppo gastrointestinal hemorrhage with mcc ms-drg 377 17273.54 17273.54 7149.07 7149.07 36153.05 36153.05 30127.54 30127.54 I 17273.54 17273.54 bcbs epo digestive malignancy with cc ms-drg 375 10903.77 10903.77 5416.71 5416.71 29958.38 29958.38 24965.32 24965.32 I 10903.77 10903.77 bcbs hmo digestive malignancy with cc ms-drg 375 10903.77 10903.77 5416.71 5416.71 29958.38 29958.38 24965.32 24965.32 I 10903.77 10903.77 bcbs hmo digestive malignancy with cc ms-drg 375 10903.77 10903.77 5416.71 5416.71 29958.38 29958.38 24965.32 24965.32 I 10903.77 10903.77 bcbs pos digestive malignancy with cc ms-drg 375 10903.77 10903.77 5416.71 5416.71 29958.38 29958.38 24965.32 24965.32 I 10903.77 10903.77 bcbs ppo digestive malignancy with cc ms-drg 375 10903.77 10903.77 5416.71 5416.71 29958.38 29958.38 24965.32 24965.32 I 10903.77 10903.77 bcbs epo other digestive system o.r. procedures with cc ms-drg 357 21321.98 21321.98 6683.22 6683.22 62148.72 62148.72 51790.6 51790.6 I 21321.98 21321.98 bcbs hmo other digestive system o.r. procedures with cc ms-drg 357 21321.98 21321.98 6683.22 6683.22 62148.72 62148.72 51790.6 51790.6 I 21321.98 21321.98 bcbs hmo other digestive system o.r. procedures with cc ms-drg 357 21321.98 21321.98 6683.22 6683.22 62148.72 62148.72 51790.6 51790.6 I 21321.98 21321.98 bcbs pos other digestive system o.r. procedures with cc ms-drg 357 21321.98 21321.98 6683.22 6683.22 62148.72 62148.72 51790.6 51790.6 I 21321.98 21321.98 bcbs ppo other digestive system o.r. procedures with cc ms-drg 357 21321.98 21321.98 6683.22 6683.22 62148.72 62148.72 51790.6 51790.6 I 21321.98 21321.98 bcbs epo hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 19392.75 19392.75 bcbs hmo hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 19392.75 19392.75 bcbs hmo hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 19392.75 19392.75 bcbs pos hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 19392.75 19392.75 bcbs ppo hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 19392.75 19392.75 bcbs epo inguinal and femoral hernia procedures without cc/mcc ms-drg 352 7123.35 7123.35 7123.35 7123.35 32227.27 32227.27 26856.06 26856.06 I 7123.35 7123.35 bcbs hmo inguinal and femoral hernia procedures without cc/mcc ms-drg 352 7123.35 7123.35 7123.35 7123.35 32227.27 32227.27 26856.06 26856.06 I 7123.35 7123.35 bcbs hmo inguinal and femoral hernia procedures without cc/mcc ms-drg 352 7123.35 7123.35 7123.35 7123.35 32227.27 32227.27 26856.06 26856.06 I 7123.35 7123.35 bcbs pos inguinal and femoral hernia procedures without cc/mcc ms-drg 352 7123.35 7123.35 7123.35 7123.35 32227.27 32227.27 26856.06 26856.06 I 7123.35 7123.35 bcbs ppo inguinal and femoral hernia procedures without cc/mcc ms-drg 352 7123.35 7123.35 7123.35 7123.35 32227.27 32227.27 26856.06 26856.06 I 7123.35 7123.35 bcbs epo anal and stomal procedures with cc ms-drg 348 9112.31 9112.31 8845.51 8845.51 42943.86 42943.86 35786.55 35786.55 I 8991.14 8991.14 bcbs hmo anal and stomal procedures with cc ms-drg 348 9112.31 9112.31 8845.51 8845.51 42943.86 42943.86 35786.55 35786.55 I 8991.14 8991.14 bcbs hmo anal and stomal procedures with cc ms-drg 348 9112.31 9112.31 8845.51 8845.51 42943.86 42943.86 35786.55 35786.55 I 8991.14 8991.14 bcbs pos anal and stomal procedures with cc ms-drg 348 9112.31 9112.31 8845.51 8845.51 42943.86 42943.86 35786.55 35786.55 I 8991.14 8991.14 bcbs ppo anal and stomal procedures with cc ms-drg 348 9112.31 9112.31 8845.51 8845.51 42943.86 42943.86 35786.55 35786.55 I 8991.14 8991.14 bcbs epo minor small and large bowel procedures without cc/mcc ms-drg 346 12647.52 12647.52 6210.98 6210.98 33068.78 33068.78 27557.32 27557.32 I 12647.52 12647.52 bcbs hmo minor small and large bowel procedures without cc/mcc ms-drg 346 12647.52 12647.52 6210.98 6210.98 33068.78 33068.78 27557.32 27557.32 I 12647.52 12647.52 bcbs hmo minor small and large bowel procedures without cc/mcc ms-drg 346 12647.52 12647.52 6210.98 6210.98 33068.78 33068.78 27557.32 27557.32 I 12647.52 12647.52 bcbs pos minor small and large bowel procedures without cc/mcc ms-drg 346 12647.52 12647.52 6210.98 6210.98 33068.78 33068.78 27557.32 27557.32 I 12647.52 12647.52 bcbs ppo minor small and large bowel procedures without cc/mcc ms-drg 346 12647.52 12647.52 6210.98 6210.98 33068.78 33068.78 27557.32 27557.32 I 12647.52 12647.52 bcbs epo appendectomy without complicated principal diagnosis without cc/mcc ms-drg 343 9395.5 9395.5 5698.84 5698.84 36435.43 36435.43 30362.86 30362.86 I 9395.5 9395.5 bcbs hmo appendectomy without complicated principal diagnosis without cc/mcc ms-drg 343 9395.5 9395.5 5698.84 5698.84 36435.43 36435.43 30362.86 30362.86 I 9395.5 9395.5 bcbs hmo appendectomy without complicated principal diagnosis without cc/mcc ms-drg 343 9395.5 9395.5 5698.84 5698.84 36435.43 36435.43 30362.86 30362.86 I 9395.5 9395.5 bcbs pos appendectomy without complicated principal diagnosis without cc/mcc ms-drg 343 9395.5 9395.5 5698.84 5698.84 36435.43 36435.43 30362.86 30362.86 I 9395.5 9395.5 bcbs ppo appendectomy without complicated principal diagnosis without cc/mcc ms-drg 343 9395.5 9395.5 5698.84 5698.84 36435.43 36435.43 30362.86 30362.86 I 9395.5 9395.5 bcbs epo appendectomy with complicated principal diagnosis without cc/mcc ms-drg 340 14044.53 14044.53 7272.25 7272.25 43215.56 43215.56 36012.97 36012.97 I 14044.53 14044.53 bcbs hmo appendectomy with complicated principal diagnosis without cc/mcc ms-drg 340 14044.53 14044.53 7272.25 7272.25 43215.56 43215.56 36012.97 36012.97 I 14044.53 14044.53 bcbs hmo appendectomy with complicated principal diagnosis without cc/mcc ms-drg 340 14044.53 14044.53 7272.25 7272.25 43215.56 43215.56 36012.97 36012.97 I 14044.53 14044.53 bcbs pos appendectomy with complicated principal diagnosis without cc/mcc ms-drg 340 14044.53 14044.53 7272.25 7272.25 43215.56 43215.56 36012.97 36012.97 I 14044.53 14044.53 bcbs ppo appendectomy with complicated principal diagnosis without cc/mcc ms-drg 340 14044.53 14044.53 7272.25 7272.25 43215.56 43215.56 36012.97 36012.97 I 14044.53 14044.53 bcbs epo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 18204.75 18204.75 bcbs hmo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 18204.75 18204.75 bcbs hmo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 18204.75 18204.75 bcbs pos peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 18204.75 18204.75 bcbs ppo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 18204.75 18204.75 bcbs epo peritoneal adhesiolysis with cc ms-drg 336 21438.99 21438.99 13955.86 13955.86 80455.5 80455.5 67046.25 67046.25 I 21438.99 21438.99 bcbs hmo peritoneal adhesiolysis with cc ms-drg 336 21438.99 21438.99 13955.86 13955.86 80455.5 80455.5 67046.25 67046.25 I 21438.99 21438.99 bcbs hmo peritoneal adhesiolysis with cc ms-drg 336 21438.99 21438.99 13955.86 13955.86 80455.5 80455.5 67046.25 67046.25 I 21438.99 21438.99 bcbs pos peritoneal adhesiolysis with cc ms-drg 336 21438.99 21438.99 13955.86 13955.86 80455.5 80455.5 67046.25 67046.25 I 21438.99 21438.99 bcbs ppo peritoneal adhesiolysis with cc ms-drg 336 21438.99 21438.99 13955.86 13955.86 80455.5 80455.5 67046.25 67046.25 I 21438.99 21438.99 bcbs epo major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 11874.88 11874.88 bcbs hmo major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 11874.88 11874.88 bcbs hmo major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 11874.88 11874.88 bcbs pos major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 11874.88 11874.88 bcbs ppo major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 11874.88 11874.88 bcbs epo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 25078.08 25078.08 bcbs hmo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 25078.08 25078.08 bcbs hmo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 25078.08 25078.08 bcbs pos major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 25078.08 25078.08 bcbs ppo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 25078.08 25078.08 bcbs epo major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 36464.38 36464.38 bcbs hmo major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 36464.38 36464.38 bcbs hmo major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 36464.38 36464.38 bcbs pos major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 36464.38 36464.38 bcbs ppo major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 36464.38 36464.38 bcbs epo "stomach, esophageal and duodenal procedures without cc/mcc" ms-drg 328 13958.64 13958.64 5175.14 5175.14 49664.04 49664.04 41386.7 41386.7 I 13958.64 13958.64 bcbs hmo "stomach, esophageal and duodenal procedures without cc/mcc" ms-drg 328 13958.64 13958.64 5175.14 5175.14 49664.04 49664.04 41386.7 41386.7 I 13958.64 13958.64 bcbs hmo "stomach, esophageal and duodenal procedures without cc/mcc" ms-drg 328 13958.64 13958.64 5175.14 5175.14 49664.04 49664.04 41386.7 41386.7 I 13958.64 13958.64 bcbs pos "stomach, esophageal and duodenal procedures without cc/mcc" ms-drg 328 13958.64 13958.64 5175.14 5175.14 49664.04 49664.04 41386.7 41386.7 I 13958.64 13958.64 bcbs ppo "stomach, esophageal and duodenal procedures without cc/mcc" ms-drg 328 13958.64 13958.64 5175.14 5175.14 49664.04 49664.04 41386.7 41386.7 I 13958.64 13958.64 bcbs epo other circulatory system diagnoses with mcc ms-drg 314 22467.12 22467.12 10250.63 10250.63 60337.15 60337.15 50280.96 50280.96 I 22467.12 22467.12 bcbs hmo other circulatory system diagnoses with mcc ms-drg 314 22467.12 22467.12 10250.63 10250.63 60337.15 60337.15 50280.96 50280.96 I 22467.12 22467.12 bcbs hmo other circulatory system diagnoses with mcc ms-drg 314 22467.12 22467.12 10250.63 10250.63 60337.15 60337.15 50280.96 50280.96 I 22467.12 22467.12 bcbs pos other circulatory system diagnoses with mcc ms-drg 314 22467.12 22467.12 10250.63 10250.63 60337.15 60337.15 50280.96 50280.96 I 22467.12 22467.12 bcbs ppo other circulatory system diagnoses with mcc ms-drg 314 22467.12 22467.12 10250.63 10250.63 60337.15 60337.15 50280.96 50280.96 I 22467.12 22467.12 bcbs epo chest pain ms-drg 313 5722.44 5722.44 3212.87 3212.87 19324.42 19324.42 16103.68 16103.68 I 5722.44 5722.44 bcbs hmo chest pain ms-drg 313 5722.44 5722.44 3212.87 3212.87 19324.42 19324.42 16103.68 16103.68 I 5722.44 5722.44 bcbs hmo chest pain ms-drg 313 5722.44 5722.44 3212.87 3212.87 19324.42 19324.42 16103.68 16103.68 I 5722.44 5722.44 bcbs pos chest pain ms-drg 313 5722.44 5722.44 3212.87 3212.87 19324.42 19324.42 16103.68 16103.68 I 5722.44 5722.44 bcbs ppo chest pain ms-drg 313 5722.44 5722.44 3212.87 3212.87 19324.42 19324.42 16103.68 16103.68 I 5722.44 5722.44 bcbs epo "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 6298.42 6298.42 bcbs hmo "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 6298.42 6298.42 bcbs hmo "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 6298.42 6298.42 bcbs pos "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 6298.42 6298.42 bcbs ppo "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 6298.42 6298.42 bcbs epo "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 6298.42 6298.42 bcbs hmo "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 6298.42 6298.42 bcbs hmo "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 6298.42 6298.42 bcbs pos "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 6298.42 6298.42 bcbs ppo "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 6298.42 6298.42 bcbs epo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 6328.13 6328.13 bcbs hmo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 6328.13 6328.13 bcbs hmo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 6328.13 6328.13 bcbs pos cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 6328.13 6328.13 bcbs ppo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 6328.13 6328.13 bcbs epo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5976.75 5976.75 bcbs hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5976.75 5976.75 bcbs hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5976.75 5976.75 bcbs pos cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5976.75 5976.75 bcbs ppo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5976.75 5976.75 bcbs epo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 8412.43 8412.43 bcbs hmo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 8412.43 8412.43 bcbs hmo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 8412.43 8412.43 bcbs pos heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 8412.43 8412.43 bcbs ppo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 8412.43 8412.43 bcbs epo Removal (less than 3 centimeters) tissue growth beneath the skin in abdominal wall cpt 22902 3796.56 3796.56 1196.5 1196.5 19428.76 19428.76 16190.63 16190.63 O 3796.56 3796.56 bcbs hmo Removal (less than 3 centimeters) tissue growth beneath the skin in abdominal wall cpt 22902 3796.56 3796.56 1196.5 1196.5 19428.76 19428.76 16190.63 16190.63 O 3796.56 3796.56 bcbs hmo Removal (less than 3 centimeters) tissue growth beneath the skin in abdominal wall cpt 22902 3796.56 3796.56 1196.5 1196.5 19428.76 19428.76 16190.63 16190.63 O 3796.56 3796.56 bcbs pos Removal (less than 3 centimeters) tissue growth beneath the skin in abdominal wall cpt 22902 3796.56 3796.56 1196.5 1196.5 19428.76 19428.76 16190.63 16190.63 O 3796.56 3796.56 bcbs ppo Removal (less than 3 centimeters) tissue growth beneath the skin in abdominal wall cpt 22902 3796.56 3796.56 1196.5 1196.5 19428.76 19428.76 16190.63 16190.63 O 3796.56 3796.56 bcbs epo "Procedure on abdomen, muscle or bone" cpt 22999 8063.39 8063.39 4294.86 4294.86 32700.88 32700.88 27250.73 27250.73 O 8063.39 8063.39 bcbs hmo "Procedure on abdomen, muscle or bone" cpt 22999 8063.39 8063.39 4294.86 4294.86 32700.88 32700.88 27250.73 27250.73 O 8063.39 8063.39 bcbs hmo "Procedure on abdomen, muscle or bone" cpt 22999 8063.39 8063.39 4294.86 4294.86 32700.88 32700.88 27250.73 27250.73 O 8063.39 8063.39 bcbs pos "Procedure on abdomen, muscle or bone" cpt 22999 8063.39 8063.39 4294.86 4294.86 32700.88 32700.88 27250.73 27250.73 O 8063.39 8063.39 bcbs ppo "Procedure on abdomen, muscle or bone" cpt 22999 8063.39 8063.39 4294.86 4294.86 32700.88 32700.88 27250.73 27250.73 O 8063.39 8063.39 bcbs epo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 13610.5 13610.5 bcbs hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 13610.5 13610.5 bcbs hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 13610.5 13610.5 bcbs pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 13610.5 13610.5 bcbs ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 13610.5 13610.5 bcbs epo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 11462.98 11462.98 bcbs hmo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 11462.98 11462.98 bcbs hmo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 11462.98 11462.98 bcbs pos "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 11462.98 11462.98 bcbs ppo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 11462.98 11462.98 bcbs epo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 23670.85 23670.85 bcbs hmo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 23670.85 23670.85 bcbs hmo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 23670.85 23670.85 bcbs pos "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 23670.85 23670.85 bcbs ppo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 23670.85 23670.85 bcbs epo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 1560.4 1560.4 bcbs hmo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 1560.4 1560.4 bcbs hmo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 1560.4 1560.4 bcbs pos Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 1560.4 1560.4 bcbs ppo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 1560.4 1560.4 bcbs epo "Repair of torn tendons of shoulder (rotator cuff), open procedure, chronic or old" cpt 23412 9091.8 9091.8 9091.8 9091.8 37389.38 37389.38 31157.82 31157.82 O 9091.8 9091.8 bcbs hmo "Repair of torn tendons of shoulder (rotator cuff), open procedure, chronic or old" cpt 23412 9091.8 9091.8 9091.8 9091.8 37389.38 37389.38 31157.82 31157.82 O 9091.8 9091.8 bcbs hmo "Repair of torn tendons of shoulder (rotator cuff), open procedure, chronic or old" cpt 23412 9091.8 9091.8 9091.8 9091.8 37389.38 37389.38 31157.82 31157.82 O 9091.8 9091.8 bcbs pos "Repair of torn tendons of shoulder (rotator cuff), open procedure, chronic or old" cpt 23412 9091.8 9091.8 9091.8 9091.8 37389.38 37389.38 31157.82 31157.82 O 9091.8 9091.8 bcbs ppo "Repair of torn tendons of shoulder (rotator cuff), open procedure, chronic or old" cpt 23412 9091.8 9091.8 9091.8 9091.8 37389.38 37389.38 31157.82 31157.82 O 9091.8 9091.8 bcbs epo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 13020.2 13020.2 bcbs hmo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 13020.2 13020.2 bcbs hmo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 13020.2 13020.2 bcbs pos "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 13020.2 13020.2 bcbs ppo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 13020.2 13020.2 bcbs epo "acute myocardial infarction, discharged alive with mcc" ms-drg 280 19765.14 19765.14 8442.33 8442.33 60541.62 60541.62 50451.35 50451.35 I 19765.14 19765.14 bcbs hmo "acute myocardial infarction, discharged alive with mcc" ms-drg 280 19765.14 19765.14 8442.33 8442.33 60541.62 60541.62 50451.35 50451.35 I 19765.14 19765.14 bcbs hmo "acute myocardial infarction, discharged alive with mcc" ms-drg 280 19765.14 19765.14 8442.33 8442.33 60541.62 60541.62 50451.35 50451.35 I 19765.14 19765.14 bcbs pos "acute myocardial infarction, discharged alive with mcc" ms-drg 280 19765.14 19765.14 8442.33 8442.33 60541.62 60541.62 50451.35 50451.35 I 19765.14 19765.14 bcbs ppo "acute myocardial infarction, discharged alive with mcc" ms-drg 280 19765.14 19765.14 8442.33 8442.33 60541.62 60541.62 50451.35 50451.35 I 19765.14 19765.14 bcbs epo other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 34817.44 34817.44 bcbs hmo other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 34817.44 34817.44 bcbs hmo other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 34817.44 34817.44 bcbs pos other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 34817.44 34817.44 bcbs ppo other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 34817.44 34817.44 bcbs epo aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 43254.05 43254.05 bcbs hmo aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 43254.05 43254.05 bcbs hmo aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 43254.05 43254.05 bcbs pos aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 43254.05 43254.05 bcbs ppo aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 43254.05 43254.05 bcbs epo Closed treatment of shoulder dislocation with manipulation under anesthesia cpt 23655 2522.8 2522.8 2522.8 2522.8 4501.7 4501.7 3751.42 3751.42 O 2522.8 2522.8 bcbs hmo Closed treatment of shoulder dislocation with manipulation under anesthesia cpt 23655 2522.8 2522.8 2522.8 2522.8 4501.7 4501.7 3751.42 3751.42 O 2522.8 2522.8 bcbs hmo Closed treatment of shoulder dislocation with manipulation under anesthesia cpt 23655 2522.8 2522.8 2522.8 2522.8 4501.7 4501.7 3751.42 3751.42 O 2522.8 2522.8 bcbs pos Closed treatment of shoulder dislocation with manipulation under anesthesia cpt 23655 2522.8 2522.8 2522.8 2522.8 4501.7 4501.7 3751.42 3751.42 O 2522.8 2522.8 bcbs ppo Closed treatment of shoulder dislocation with manipulation under anesthesia cpt 23655 2522.8 2522.8 2522.8 2522.8 4501.7 4501.7 3751.42 3751.42 O 2522.8 2522.8 bcbs epo percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 26746.13 26746.13 bcbs hmo percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 26746.13 26746.13 bcbs hmo percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 26746.13 26746.13 bcbs pos percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 26746.13 26746.13 bcbs ppo percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 26746.13 26746.13 bcbs epo percutaneous cardiovascular procedures with non-drug-eluting stent without mcc ms-drg 249 19270.14 19270.14 11166.95 11166.95 79497.7 79497.7 66248.08 66248.08 I 19270.14 19270.14 bcbs hmo percutaneous cardiovascular procedures with non-drug-eluting stent without mcc ms-drg 249 19270.14 19270.14 11166.95 11166.95 79497.7 79497.7 66248.08 66248.08 I 19270.14 19270.14 bcbs hmo percutaneous cardiovascular procedures with non-drug-eluting stent without mcc ms-drg 249 19270.14 19270.14 11166.95 11166.95 79497.7 79497.7 66248.08 66248.08 I 19270.14 19270.14 bcbs pos percutaneous cardiovascular procedures with non-drug-eluting stent without mcc ms-drg 249 19270.14 19270.14 11166.95 11166.95 79497.7 79497.7 66248.08 66248.08 I 19270.14 19270.14 bcbs ppo percutaneous cardiovascular procedures with non-drug-eluting stent without mcc ms-drg 249 19270.14 19270.14 11166.95 11166.95 79497.7 79497.7 66248.08 66248.08 I 19270.14 19270.14 bcbs epo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 23415.96 23415.96 bcbs hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 23415.96 23415.96 bcbs hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 23415.96 23415.96 bcbs pos percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 23415.96 23415.96 bcbs ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 23415.96 23415.96 bcbs epo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 36253.66 36253.66 bcbs hmo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 36253.66 36253.66 bcbs hmo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 36253.66 36253.66 bcbs pos percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 36253.66 36253.66 bcbs ppo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 36253.66 36253.66 bcbs epo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 20821.91 20821.91 bcbs hmo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 20821.91 20821.91 bcbs hmo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 20821.91 20821.91 bcbs pos permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 20821.91 20821.91 bcbs ppo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 20821.91 20821.91 bcbs epo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 36670.41 36670.41 bcbs hmo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 36670.41 36670.41 bcbs hmo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 36670.41 36670.41 bcbs pos coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 36670.41 36670.41 bcbs ppo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 36670.41 36670.41 bcbs epo Incision or the tendon covering on the top side of the wrist cpt 25000 3749.59 3749.59 1250.16 1250.16 17430.41 17430.41 14525.34 14525.34 O 3749.59 3749.59 bcbs hmo Incision or the tendon covering on the top side of the wrist cpt 25000 3749.59 3749.59 1250.16 1250.16 17430.41 17430.41 14525.34 14525.34 O 3749.59 3749.59 bcbs hmo Incision or the tendon covering on the top side of the wrist cpt 25000 3749.59 3749.59 1250.16 1250.16 17430.41 17430.41 14525.34 14525.34 O 3749.59 3749.59 bcbs pos Incision or the tendon covering on the top side of the wrist cpt 25000 3749.59 3749.59 1250.16 1250.16 17430.41 17430.41 14525.34 14525.34 O 3749.59 3749.59 bcbs ppo Incision or the tendon covering on the top side of the wrist cpt 25000 3749.59 3749.59 1250.16 1250.16 17430.41 17430.41 14525.34 14525.34 O 3749.59 3749.59 bcbs epo "Removal of cyst at wrist, initial or primary" cpt 25111 2879.76 2879.76 1136.27 1136.27 17644.34 17644.34 14703.62 14703.62 O 2879.76 2879.76 bcbs hmo "Removal of cyst at wrist, initial or primary" cpt 25111 2879.76 2879.76 1136.27 1136.27 17644.34 17644.34 14703.62 14703.62 O 2879.76 2879.76 bcbs hmo "Removal of cyst at wrist, initial or primary" cpt 25111 2879.76 2879.76 1136.27 1136.27 17644.34 17644.34 14703.62 14703.62 O 2879.76 2879.76 bcbs pos "Removal of cyst at wrist, initial or primary" cpt 25111 2879.76 2879.76 1136.27 1136.27 17644.34 17644.34 14703.62 14703.62 O 2879.76 2879.76 bcbs ppo "Removal of cyst at wrist, initial or primary" cpt 25111 2879.76 2879.76 1136.27 1136.27 17644.34 17644.34 14703.62 14703.62 O 2879.76 2879.76 bcbs epo coronary bypass without cardiac catheterization with mcc ms-drg 235 50073.04 50073.04 34443.24 34443.24 225842.78 225842.78 188202.32 188202.32 I 50073.04 50073.04 bcbs hmo coronary bypass without cardiac catheterization with mcc ms-drg 235 50073.04 50073.04 34443.24 34443.24 225842.78 225842.78 188202.32 188202.32 I 50073.04 50073.04 bcbs hmo coronary bypass without cardiac catheterization with mcc ms-drg 235 50073.04 50073.04 34443.24 34443.24 225842.78 225842.78 188202.32 188202.32 I 50073.04 50073.04 bcbs pos coronary bypass without cardiac catheterization with mcc ms-drg 235 50073.04 50073.04 34443.24 34443.24 225842.78 225842.78 188202.32 188202.32 I 50073.04 50073.04 bcbs ppo coronary bypass without cardiac catheterization with mcc ms-drg 235 50073.04 50073.04 34443.24 34443.24 225842.78 225842.78 188202.32 188202.32 I 50073.04 50073.04 bcbs epo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 52095.13 52095.13 bcbs hmo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 52095.13 52095.13 bcbs hmo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 52095.13 52095.13 bcbs pos coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 52095.13 52095.13 bcbs ppo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 52095.13 52095.13 bcbs epo other cardiothoracic procedures with mcc ms-drg 228 89820.91 89820.91 36345.66 36345.66 120556.57 120556.57 100463.81 100463.81 I 89820.91 89820.91 bcbs hmo other cardiothoracic procedures with mcc ms-drg 228 89820.91 89820.91 36345.66 36345.66 120556.57 120556.57 100463.81 100463.81 I 89820.91 89820.91 bcbs hmo other cardiothoracic procedures with mcc ms-drg 228 89820.91 89820.91 36345.66 36345.66 120556.57 120556.57 100463.81 100463.81 I 89820.91 89820.91 bcbs pos other cardiothoracic procedures with mcc ms-drg 228 89820.91 89820.91 36345.66 36345.66 120556.57 120556.57 100463.81 100463.81 I 89820.91 89820.91 bcbs ppo other cardiothoracic procedures with mcc ms-drg 228 89820.91 89820.91 36345.66 36345.66 120556.57 120556.57 100463.81 100463.81 I 89820.91 89820.91 bcbs epo Open treatment of broken of lower forearm or growth plate separation with insertion of hardware of 2 fragments cpt 25608 7889.33 7889.33 4927.02 4927.02 34718.63 34718.63 28932.19 28932.19 O 7889.33 7889.33 bcbs hmo Open treatment of broken of lower forearm or growth plate separation with insertion of hardware of 2 fragments cpt 25608 7889.33 7889.33 4927.02 4927.02 34718.63 34718.63 28932.19 28932.19 O 7889.33 7889.33 bcbs hmo Open treatment of broken of lower forearm or growth plate separation with insertion of hardware of 2 fragments cpt 25608 7889.33 7889.33 4927.02 4927.02 34718.63 34718.63 28932.19 28932.19 O 7889.33 7889.33 bcbs pos Open treatment of broken of lower forearm or growth plate separation with insertion of hardware of 2 fragments cpt 25608 7889.33 7889.33 4927.02 4927.02 34718.63 34718.63 28932.19 28932.19 O 7889.33 7889.33 bcbs ppo Open treatment of broken of lower forearm or growth plate separation with insertion of hardware of 2 fragments cpt 25608 7889.33 7889.33 4927.02 4927.02 34718.63 34718.63 28932.19 28932.19 O 7889.33 7889.33 bcbs epo Open treatment of broken wrist cpt 25652 7889.33 7889.33 4903.68 4903.68 37667.29 37667.29 31389.41 31389.41 O 7889.33 7889.33 bcbs hmo Open treatment of broken wrist cpt 25652 7889.33 7889.33 4903.68 4903.68 37667.29 37667.29 31389.41 31389.41 O 7889.33 7889.33 bcbs hmo Open treatment of broken wrist cpt 25652 7889.33 7889.33 4903.68 4903.68 37667.29 37667.29 31389.41 31389.41 O 7889.33 7889.33 bcbs pos Open treatment of broken wrist cpt 25652 7889.33 7889.33 4903.68 4903.68 37667.29 37667.29 31389.41 31389.41 O 7889.33 7889.33 bcbs ppo Open treatment of broken wrist cpt 25652 7889.33 7889.33 4903.68 4903.68 37667.29 37667.29 31389.41 31389.41 O 7889.33 7889.33 bcbs epo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 54699.55 54699.55 bcbs hmo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 54699.55 54699.55 bcbs hmo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 54699.55 54699.55 bcbs pos cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 54699.55 54699.55 bcbs ppo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 54699.55 54699.55 bcbs epo respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 26637.75 26637.75 bcbs hmo respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 26637.75 26637.75 bcbs hmo respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 26637.75 26637.75 bcbs pos respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 26637.75 26637.75 bcbs ppo respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 26637.75 26637.75 bcbs epo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 3554.71 3554.71 bcbs hmo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 3554.71 3554.71 bcbs hmo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 3554.71 3554.71 bcbs pos Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 3554.71 3554.71 bcbs ppo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 3554.71 3554.71 bcbs epo respiratory signs and symptoms ms-drg 204 5762.49 5762.49 3725.66 3725.66 11897.69 11897.69 9914.74 9914.74 I 3725.66 3725.66 bcbs hmo respiratory signs and symptoms ms-drg 204 5762.49 5762.49 3725.66 3725.66 11897.69 11897.69 9914.74 9914.74 I 3725.66 3725.66 bcbs hmo respiratory signs and symptoms ms-drg 204 5762.49 5762.49 3725.66 3725.66 11897.69 11897.69 9914.74 9914.74 I 3725.66 3725.66 bcbs pos respiratory signs and symptoms ms-drg 204 5762.49 5762.49 3725.66 3725.66 11897.69 11897.69 9914.74 9914.74 I 3725.66 3725.66 bcbs ppo respiratory signs and symptoms ms-drg 204 5762.49 5762.49 3725.66 3725.66 11897.69 11897.69 9914.74 9914.74 I 3725.66 3725.66 bcbs epo bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 7954.58 7954.58 bcbs hmo bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 7954.58 7954.58 bcbs hmo bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 7954.58 7954.58 bcbs pos bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 7954.58 7954.58 bcbs ppo bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 7954.58 7954.58 bcbs epo interstitial lung disease with mcc ms-drg 196 16052.47 16052.47 10645.76 10645.76 50645.26 50645.26 42204.38 42204.38 I 16052.47 16052.47 bcbs hmo interstitial lung disease with mcc ms-drg 196 16052.47 16052.47 10645.76 10645.76 50645.26 50645.26 42204.38 42204.38 I 16052.47 16052.47 bcbs hmo interstitial lung disease with mcc ms-drg 196 16052.47 16052.47 10645.76 10645.76 50645.26 50645.26 42204.38 42204.38 I 16052.47 16052.47 bcbs pos interstitial lung disease with mcc ms-drg 196 16052.47 16052.47 10645.76 10645.76 50645.26 50645.26 42204.38 42204.38 I 16052.47 16052.47 bcbs ppo interstitial lung disease with mcc ms-drg 196 16052.47 16052.47 10645.76 10645.76 50645.26 50645.26 42204.38 42204.38 I 16052.47 16052.47 bcbs epo Removal (less than 1.5 centimeters) muscle growth of hand or finger cpt 26116 3848.24 3848.24 3848.24 3848.24 20450.2 20450.2 17041.83 17041.83 O 3848.24 3848.24 bcbs hmo Removal (less than 1.5 centimeters) muscle growth of hand or finger cpt 26116 3848.24 3848.24 3848.24 3848.24 20450.2 20450.2 17041.83 17041.83 O 3848.24 3848.24 bcbs hmo Removal (less than 1.5 centimeters) muscle growth of hand or finger cpt 26116 3848.24 3848.24 3848.24 3848.24 20450.2 20450.2 17041.83 17041.83 O 3848.24 3848.24 bcbs pos Removal (less than 1.5 centimeters) muscle growth of hand or finger cpt 26116 3848.24 3848.24 3848.24 3848.24 20450.2 20450.2 17041.83 17041.83 O 3848.24 3848.24 bcbs ppo Removal (less than 1.5 centimeters) muscle growth of hand or finger cpt 26116 3848.24 3848.24 3848.24 3848.24 20450.2 20450.2 17041.83 17041.83 O 3848.24 3848.24 bcbs epo simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 8418.87 8418.87 bcbs hmo simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 8418.87 8418.87 bcbs hmo simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 8418.87 8418.87 bcbs pos simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 8418.87 8418.87 bcbs ppo simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 8418.87 8418.87 bcbs epo "Insertion of hardware to broken finger, accessed through the skin" cpt 26608 10600.32 10600.32 2425.05 2425.05 22144.12 22144.12 18453.43 18453.43 O 10600.32 10600.32 bcbs hmo "Insertion of hardware to broken finger, accessed through the skin" cpt 26608 10600.32 10600.32 2425.05 2425.05 22144.12 22144.12 18453.43 18453.43 O 10600.32 10600.32 bcbs hmo "Insertion of hardware to broken finger, accessed through the skin" cpt 26608 10600.32 10600.32 2425.05 2425.05 22144.12 22144.12 18453.43 18453.43 O 10600.32 10600.32 bcbs pos "Insertion of hardware to broken finger, accessed through the skin" cpt 26608 10600.32 10600.32 2425.05 2425.05 22144.12 22144.12 18453.43 18453.43 O 10600.32 10600.32 bcbs ppo "Insertion of hardware to broken finger, accessed through the skin" cpt 26608 10600.32 10600.32 2425.05 2425.05 22144.12 22144.12 18453.43 18453.43 O 10600.32 10600.32 bcbs epo Open treatment of fracture of bone in the midportion of the hand between the wrist and fingers cpt 26615 5398.71 5398.71 2297.73 2297.73 24889.74 24889.74 20741.45 20741.45 O 5398.71 5398.71 bcbs hmo Open treatment of fracture of bone in the midportion of the hand between the wrist and fingers cpt 26615 5398.71 5398.71 2297.73 2297.73 24889.74 24889.74 20741.45 20741.45 O 5398.71 5398.71 bcbs hmo Open treatment of fracture of bone in the midportion of the hand between the wrist and fingers cpt 26615 5398.71 5398.71 2297.73 2297.73 24889.74 24889.74 20741.45 20741.45 O 5398.71 5398.71 bcbs pos Open treatment of fracture of bone in the midportion of the hand between the wrist and fingers cpt 26615 5398.71 5398.71 2297.73 2297.73 24889.74 24889.74 20741.45 20741.45 O 5398.71 5398.71 bcbs ppo Open treatment of fracture of bone in the midportion of the hand between the wrist and fingers cpt 26615 5398.71 5398.71 2297.73 2297.73 24889.74 24889.74 20741.45 20741.45 O 5398.71 5398.71 bcbs epo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9428.53 9428.53 bcbs hmo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9428.53 9428.53 bcbs hmo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9428.53 9428.53 bcbs pos simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9428.53 9428.53 bcbs ppo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 9428.53 9428.53 bcbs epo "Insertion of hardware to broken finger or thumb, accessed through the skin" cpt 26756 5946.93 5946.93 5946.93 5946.93 18011.06 18011.06 15009.22 15009.22 O 5946.93 5946.93 bcbs hmo "Insertion of hardware to broken finger or thumb, accessed through the skin" cpt 26756 5946.93 5946.93 5946.93 5946.93 18011.06 18011.06 15009.22 15009.22 O 5946.93 5946.93 bcbs hmo "Insertion of hardware to broken finger or thumb, accessed through the skin" cpt 26756 5946.93 5946.93 5946.93 5946.93 18011.06 18011.06 15009.22 15009.22 O 5946.93 5946.93 bcbs pos "Insertion of hardware to broken finger or thumb, accessed through the skin" cpt 26756 5946.93 5946.93 5946.93 5946.93 18011.06 18011.06 15009.22 15009.22 O 5946.93 5946.93 bcbs ppo "Insertion of hardware to broken finger or thumb, accessed through the skin" cpt 26756 5946.93 5946.93 5946.93 5946.93 18011.06 18011.06 15009.22 15009.22 O 5946.93 5946.93 bcbs epo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 17066.39 17066.39 bcbs hmo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 17066.39 17066.39 bcbs hmo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 17066.39 17066.39 bcbs pos simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 17066.39 17066.39 bcbs ppo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 17066.39 17066.39 bcbs epo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 6150.25 6150.25 bcbs hmo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 6150.25 6150.25 bcbs hmo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 6150.25 6150.25 bcbs pos chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 6150.25 6150.25 bcbs ppo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 6150.25 6150.25 bcbs epo chronic obstructive pulmonary disease with cc ms-drg 191 7503.57 7503.57 4026.99 4026.99 20630.96 20630.96 17192.47 17192.47 I 7503.57 7503.57 bcbs hmo chronic obstructive pulmonary disease with cc ms-drg 191 7503.57 7503.57 4026.99 4026.99 20630.96 20630.96 17192.47 17192.47 I 7503.57 7503.57 bcbs hmo chronic obstructive pulmonary disease with cc ms-drg 191 7503.57 7503.57 4026.99 4026.99 20630.96 20630.96 17192.47 17192.47 I 7503.57 7503.57 bcbs pos chronic obstructive pulmonary disease with cc ms-drg 191 7503.57 7503.57 4026.99 4026.99 20630.96 20630.96 17192.47 17192.47 I 7503.57 7503.57 bcbs ppo chronic obstructive pulmonary disease with cc ms-drg 191 7503.57 7503.57 4026.99 4026.99 20630.96 20630.96 17192.47 17192.47 I 7503.57 7503.57 bcbs epo chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 9844.32 9844.32 bcbs hmo chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 9844.32 9844.32 bcbs hmo chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 9844.32 9844.32 bcbs pos chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 9844.32 9844.32 bcbs ppo chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 9844.32 9844.32 bcbs epo pleural effusion with mcc ms-drg 186 9570.63 9570.63 9567.47 9567.47 47108.65 47108.65 39257.21 39257.21 I 9567.47 9567.47 bcbs hmo pleural effusion with mcc ms-drg 186 9570.63 9570.63 9567.47 9567.47 47108.65 47108.65 39257.21 39257.21 I 9567.47 9567.47 bcbs hmo pleural effusion with mcc ms-drg 186 9570.63 9570.63 9567.47 9567.47 47108.65 47108.65 39257.21 39257.21 I 9567.47 9567.47 bcbs pos pleural effusion with mcc ms-drg 186 9570.63 9570.63 9567.47 9567.47 47108.65 47108.65 39257.21 39257.21 I 9567.47 9567.47 bcbs ppo pleural effusion with mcc ms-drg 186 9570.63 9570.63 9567.47 9567.47 47108.65 47108.65 39257.21 39257.21 I 9567.47 9567.47 bcbs epo major chest trauma with cc ms-drg 184 16158.85 16158.85 6519.09 6519.09 29643.79 29643.79 24703.16 24703.16 I 16158.85 16158.85 bcbs hmo major chest trauma with cc ms-drg 184 16158.85 16158.85 6519.09 6519.09 29643.79 29643.79 24703.16 24703.16 I 16158.85 16158.85 bcbs hmo major chest trauma with cc ms-drg 184 16158.85 16158.85 6519.09 6519.09 29643.79 29643.79 24703.16 24703.16 I 16158.85 16158.85 bcbs pos major chest trauma with cc ms-drg 184 16158.85 16158.85 6519.09 6519.09 29643.79 29643.79 24703.16 24703.16 I 16158.85 16158.85 bcbs ppo major chest trauma with cc ms-drg 184 16158.85 16158.85 6519.09 6519.09 29643.79 29643.79 24703.16 24703.16 I 16158.85 16158.85 bcbs epo respiratory infections and inflammations without cc/mcc ms-drg 179 9651.21 9651.21 3828.24 3828.24 10946.44 10946.44 9122.03 9122.03 I 9651.21 9651.21 bcbs hmo respiratory infections and inflammations without cc/mcc ms-drg 179 9651.21 9651.21 3828.24 3828.24 10946.44 10946.44 9122.03 9122.03 I 9651.21 9651.21 bcbs hmo respiratory infections and inflammations without cc/mcc ms-drg 179 9651.21 9651.21 3828.24 3828.24 10946.44 10946.44 9122.03 9122.03 I 9651.21 9651.21 bcbs pos respiratory infections and inflammations without cc/mcc ms-drg 179 9651.21 9651.21 3828.24 3828.24 10946.44 10946.44 9122.03 9122.03 I 9651.21 9651.21 bcbs ppo respiratory infections and inflammations without cc/mcc ms-drg 179 9651.21 9651.21 3828.24 3828.24 10946.44 10946.44 9122.03 9122.03 I 9651.21 9651.21 bcbs epo respiratory infections and inflammations with cc ms-drg 178 17495.91 17495.91 1860.14 1860.14 21426.17 21426.17 17855.14 17855.14 I 17495.91 17495.91 bcbs hmo respiratory infections and inflammations with cc ms-drg 178 17495.91 17495.91 1860.14 1860.14 21426.17 21426.17 17855.14 17855.14 I 17495.91 17495.91 bcbs hmo respiratory infections and inflammations with cc ms-drg 178 17495.91 17495.91 1860.14 1860.14 21426.17 21426.17 17855.14 17855.14 I 17495.91 17495.91 bcbs pos respiratory infections and inflammations with cc ms-drg 178 17495.91 17495.91 1860.14 1860.14 21426.17 21426.17 17855.14 17855.14 I 17495.91 17495.91 bcbs ppo respiratory infections and inflammations with cc ms-drg 178 17495.91 17495.91 1860.14 1860.14 21426.17 21426.17 17855.14 17855.14 I 17495.91 17495.91 bcbs epo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 20820.38 20820.38 bcbs hmo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 20820.38 20820.38 bcbs hmo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 20820.38 20820.38 bcbs pos respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 20820.38 20820.38 bcbs ppo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 20820.38 20820.38 bcbs epo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 12434.84 12434.84 bcbs hmo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 12434.84 12434.84 bcbs hmo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 12434.84 12434.84 bcbs pos pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 12434.84 12434.84 bcbs ppo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 12434.84 12434.84 bcbs epo pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 9498.01 9498.01 bcbs hmo pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 9498.01 9498.01 bcbs hmo pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 9498.01 9498.01 bcbs pos pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 9498.01 9498.01 bcbs ppo pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 9498.01 9498.01 bcbs epo other respiratory system o.r. procedures without cc/mcc ms-drg 168 11218.51 11218.51 11218.51 11218.51 45937.34 45937.34 38281.12 38281.12 I 11218.51 11218.51 bcbs hmo other respiratory system o.r. procedures without cc/mcc ms-drg 168 11218.51 11218.51 11218.51 11218.51 45937.34 45937.34 38281.12 38281.12 I 11218.51 11218.51 bcbs hmo other respiratory system o.r. procedures without cc/mcc ms-drg 168 11218.51 11218.51 11218.51 11218.51 45937.34 45937.34 38281.12 38281.12 I 11218.51 11218.51 bcbs pos other respiratory system o.r. procedures without cc/mcc ms-drg 168 11218.51 11218.51 11218.51 11218.51 45937.34 45937.34 38281.12 38281.12 I 11218.51 11218.51 bcbs ppo other respiratory system o.r. procedures without cc/mcc ms-drg 168 11218.51 11218.51 11218.51 11218.51 45937.34 45937.34 38281.12 38281.12 I 11218.51 11218.51 bcbs epo other respiratory system o.r. procedures with cc ms-drg 167 18925.13 18925.13 5702.35 5702.35 57441.06 57441.06 47867.55 47867.55 I 18925.13 18925.13 bcbs hmo other respiratory system o.r. procedures with cc ms-drg 167 18925.13 18925.13 5702.35 5702.35 57441.06 57441.06 47867.55 47867.55 I 18925.13 18925.13 bcbs hmo other respiratory system o.r. procedures with cc ms-drg 167 18925.13 18925.13 5702.35 5702.35 57441.06 57441.06 47867.55 47867.55 I 18925.13 18925.13 bcbs pos other respiratory system o.r. procedures with cc ms-drg 167 18925.13 18925.13 5702.35 5702.35 57441.06 57441.06 47867.55 47867.55 I 18925.13 18925.13 bcbs ppo other respiratory system o.r. procedures with cc ms-drg 167 18925.13 18925.13 5702.35 5702.35 57441.06 57441.06 47867.55 47867.55 I 18925.13 18925.13 bcbs epo major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 22244.9 22244.9 bcbs hmo major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 22244.9 22244.9 bcbs hmo major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 22244.9 22244.9 bcbs pos major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 22244.9 22244.9 bcbs ppo major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 22244.9 22244.9 bcbs epo major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 25248.79 25248.79 bcbs hmo major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 25248.79 25248.79 bcbs hmo major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 25248.79 25248.79 bcbs pos major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 25248.79 25248.79 bcbs ppo major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 25248.79 25248.79 bcbs epo otitis media and uri without mcc ms-drg 153 5161.07 5161.07 1899.95 1899.95 22377.64 22377.64 18648.03 18648.03 I 4058.06 4058.06 bcbs hmo otitis media and uri without mcc ms-drg 153 5161.07 5161.07 1899.95 1899.95 22377.64 22377.64 18648.03 18648.03 I 4058.06 4058.06 bcbs hmo otitis media and uri without mcc ms-drg 153 5161.07 5161.07 1899.95 1899.95 22377.64 22377.64 18648.03 18648.03 I 4058.06 4058.06 bcbs pos otitis media and uri without mcc ms-drg 153 5161.07 5161.07 1899.95 1899.95 22377.64 22377.64 18648.03 18648.03 I 4058.06 4058.06 bcbs ppo otitis media and uri without mcc ms-drg 153 5161.07 5161.07 1899.95 1899.95 22377.64 22377.64 18648.03 18648.03 I 4058.06 4058.06 bcbs epo neurological eye disorders ms-drg 123 8425.13 8425.13 5364.25 5364.25 15278.22 15278.22 12731.85 12731.85 I 8425.13 8425.13 bcbs hmo neurological eye disorders ms-drg 123 8425.13 8425.13 5364.25 5364.25 15278.22 15278.22 12731.85 12731.85 I 8425.13 8425.13 bcbs hmo neurological eye disorders ms-drg 123 8425.13 8425.13 5364.25 5364.25 15278.22 15278.22 12731.85 12731.85 I 8425.13 8425.13 bcbs pos neurological eye disorders ms-drg 123 8425.13 8425.13 5364.25 5364.25 15278.22 15278.22 12731.85 12731.85 I 8425.13 8425.13 bcbs ppo neurological eye disorders ms-drg 123 8425.13 8425.13 5364.25 5364.25 15278.22 15278.22 12731.85 12731.85 I 8425.13 8425.13 bcbs epo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4464.61 4464.61 bcbs hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4464.61 4464.61 bcbs hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4464.61 4464.61 bcbs pos Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4464.61 4464.61 bcbs ppo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4464.61 4464.61 bcbs epo Open treatment of the outside prominence of bone of the leg (fibula) in the region of the ankle cpt 27792 7125.29 7125.29 4890.06 4890.06 32793.31 32793.31 27327.76 27327.76 O 7125.29 7125.29 bcbs hmo Open treatment of the outside prominence of bone of the leg (fibula) in the region of the ankle cpt 27792 7125.29 7125.29 4890.06 4890.06 32793.31 32793.31 27327.76 27327.76 O 7125.29 7125.29 bcbs hmo Open treatment of the outside prominence of bone of the leg (fibula) in the region of the ankle cpt 27792 7125.29 7125.29 4890.06 4890.06 32793.31 32793.31 27327.76 27327.76 O 7125.29 7125.29 bcbs pos Open treatment of the outside prominence of bone of the leg (fibula) in the region of the ankle cpt 27792 7125.29 7125.29 4890.06 4890.06 32793.31 32793.31 27327.76 27327.76 O 7125.29 7125.29 bcbs ppo Open treatment of the outside prominence of bone of the leg (fibula) in the region of the ankle cpt 27792 7125.29 7125.29 4890.06 4890.06 32793.31 32793.31 27327.76 27327.76 O 7125.29 7125.29 bcbs epo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 8027.81 8027.81 bcbs hmo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 8027.81 8027.81 bcbs hmo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 8027.81 8027.81 bcbs pos C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 8027.81 8027.81 bcbs ppo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 8027.81 8027.81 bcbs epo Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1355.6 1355.6 1355.6 1355.6 6346.06 6346.06 5288.38 5288.38 O 1355.6 1355.6 bcbs hmo Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1355.6 1355.6 1355.6 1355.6 6346.06 6346.06 5288.38 5288.38 O 1355.6 1355.6 bcbs hmo Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1355.6 1355.6 1355.6 1355.6 6346.06 6346.06 5288.38 5288.38 O 1355.6 1355.6 bcbs pos Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1355.6 1355.6 1355.6 1355.6 6346.06 6346.06 5288.38 5288.38 O 1355.6 1355.6 bcbs ppo Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1355.6 1355.6 1355.6 1355.6 6346.06 6346.06 5288.38 5288.38 O 1355.6 1355.6 bcbs epo Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 18636.78 18636.78 bcbs hmo Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 18636.78 18636.78 bcbs hmo Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 18636.78 18636.78 bcbs pos Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 18636.78 18636.78 bcbs ppo Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 18636.78 18636.78 bcbs epo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 19198.5 19198.5 bcbs hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 19198.5 19198.5 bcbs hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 19198.5 19198.5 bcbs pos Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 19198.5 19198.5 bcbs ppo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 19198.5 19198.5 bcbs epo Incision of tissues of muscle compartment of foot and/or toe cpt 28008 3179.01 3179.01 2425.05 2425.05 14330.89 14330.89 11942.41 11942.41 O 3179.01 3179.01 bcbs hmo Incision of tissues of muscle compartment of foot and/or toe cpt 28008 3179.01 3179.01 2425.05 2425.05 14330.89 14330.89 11942.41 11942.41 O 3179.01 3179.01 bcbs hmo Incision of tissues of muscle compartment of foot and/or toe cpt 28008 3179.01 3179.01 2425.05 2425.05 14330.89 14330.89 11942.41 11942.41 O 3179.01 3179.01 bcbs pos Incision of tissues of muscle compartment of foot and/or toe cpt 28008 3179.01 3179.01 2425.05 2425.05 14330.89 14330.89 11942.41 11942.41 O 3179.01 3179.01 bcbs ppo Incision of tissues of muscle compartment of foot and/or toe cpt 28008 3179.01 3179.01 2425.05 2425.05 14330.89 14330.89 11942.41 11942.41 O 3179.01 3179.01 bcbs epo Removal (less than 1.5 centimeters) tissue growth beneath the skin of foot or toe cpt 28043 3841.83 3841.83 3841.83 3841.83 17389.02 17389.02 14490.85 14490.85 O 3841.83 3841.83 bcbs hmo Removal (less than 1.5 centimeters) tissue growth beneath the skin of foot or toe cpt 28043 3841.83 3841.83 3841.83 3841.83 17389.02 17389.02 14490.85 14490.85 O 3841.83 3841.83 bcbs hmo Removal (less than 1.5 centimeters) tissue growth beneath the skin of foot or toe cpt 28043 3841.83 3841.83 3841.83 3841.83 17389.02 17389.02 14490.85 14490.85 O 3841.83 3841.83 bcbs pos Removal (less than 1.5 centimeters) tissue growth beneath the skin of foot or toe cpt 28043 3841.83 3841.83 3841.83 3841.83 17389.02 17389.02 14490.85 14490.85 O 3841.83 3841.83 bcbs ppo Removal (less than 1.5 centimeters) tissue growth beneath the skin of foot or toe cpt 28043 3841.83 3841.83 3841.83 3841.83 17389.02 17389.02 14490.85 14490.85 O 3841.83 3841.83 bcbs epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 79.34 79.34 bcbs hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 79.34 79.34 bcbs hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 79.34 79.34 bcbs pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 79.34 79.34 bcbs ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 79.34 79.34 bcbs epo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 125.2 125.2 bcbs hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 125.2 125.2 bcbs hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 125.2 125.2 bcbs pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 125.2 125.2 bcbs ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 125.2 125.2 bcbs epo Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 2997.13 2997.13 bcbs hmo Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 2997.13 2997.13 bcbs hmo Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 2997.13 2997.13 bcbs pos Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 2997.13 2997.13 bcbs ppo Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 2997.13 2997.13 bcbs epo Vaccine administration revCode 771 5297.03 5297.03 5297.03 5297.03 12608.57 12608.57 10507.14 10507.14 O 5297.03 5297.03 bcbs hmo Vaccine administration revCode 771 5297.03 5297.03 5297.03 5297.03 12608.57 12608.57 10507.14 10507.14 O 5297.03 5297.03 bcbs hmo Vaccine administration revCode 771 5297.03 5297.03 5297.03 5297.03 12608.57 12608.57 10507.14 10507.14 O 5297.03 5297.03 bcbs pos Vaccine administration revCode 771 5297.03 5297.03 5297.03 5297.03 12608.57 12608.57 10507.14 10507.14 O 5297.03 5297.03 bcbs ppo Vaccine administration revCode 771 5297.03 5297.03 5297.03 5297.03 12608.57 12608.57 10507.14 10507.14 O 5297.03 5297.03 bcbs epo "Correction of bunion, with fusion of the midfoot (metatarsal) bone and the hindfoot bone (tarsal)" cpt 28297 5382.42 5382.42 5382.42 5382.42 47414.83 47414.83 39512.36 39512.36 O 5382.42 5382.42 bcbs hmo "Correction of bunion, with fusion of the midfoot (metatarsal) bone and the hindfoot bone (tarsal)" cpt 28297 5382.42 5382.42 5382.42 5382.42 47414.83 47414.83 39512.36 39512.36 O 5382.42 5382.42 bcbs hmo "Correction of bunion, with fusion of the midfoot (metatarsal) bone and the hindfoot bone (tarsal)" cpt 28297 5382.42 5382.42 5382.42 5382.42 47414.83 47414.83 39512.36 39512.36 O 5382.42 5382.42 bcbs pos "Correction of bunion, with fusion of the midfoot (metatarsal) bone and the hindfoot bone (tarsal)" cpt 28297 5382.42 5382.42 5382.42 5382.42 47414.83 47414.83 39512.36 39512.36 O 5382.42 5382.42 bcbs ppo "Correction of bunion, with fusion of the midfoot (metatarsal) bone and the hindfoot bone (tarsal)" cpt 28297 5382.42 5382.42 5382.42 5382.42 47414.83 47414.83 39512.36 39512.36 O 5382.42 5382.42 bcbs epo Open treatment of fracture of the mid portion of the foot cpt 28485 5392.47 5392.47 5392.47 5392.47 30910.43 30910.43 25758.69 25758.69 O 5392.47 5392.47 bcbs hmo Open treatment of fracture of the mid portion of the foot cpt 28485 5392.47 5392.47 5392.47 5392.47 30910.43 30910.43 25758.69 25758.69 O 5392.47 5392.47 bcbs hmo Open treatment of fracture of the mid portion of the foot cpt 28485 5392.47 5392.47 5392.47 5392.47 30910.43 30910.43 25758.69 25758.69 O 5392.47 5392.47 bcbs pos Open treatment of fracture of the mid portion of the foot cpt 28485 5392.47 5392.47 5392.47 5392.47 30910.43 30910.43 25758.69 25758.69 O 5392.47 5392.47 bcbs ppo Open treatment of fracture of the mid portion of the foot cpt 28485 5392.47 5392.47 5392.47 5392.47 30910.43 30910.43 25758.69 25758.69 O 5392.47 5392.47 bcbs epo Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 3098.67 3098.67 bcbs hmo Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 3098.67 3098.67 bcbs hmo Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 3098.67 3098.67 bcbs pos Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 3098.67 3098.67 bcbs ppo Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 3098.67 3098.67 bcbs epo Fusion of multiple foot joints without a bone incision cpt 28730 5382.42 5382.42 5382.42 5382.42 60056.7 60056.7 50047.25 50047.25 O 5382.42 5382.42 bcbs hmo Fusion of multiple foot joints without a bone incision cpt 28730 5382.42 5382.42 5382.42 5382.42 60056.7 60056.7 50047.25 50047.25 O 5382.42 5382.42 bcbs hmo Fusion of multiple foot joints without a bone incision cpt 28730 5382.42 5382.42 5382.42 5382.42 60056.7 60056.7 50047.25 50047.25 O 5382.42 5382.42 bcbs pos Fusion of multiple foot joints without a bone incision cpt 28730 5382.42 5382.42 5382.42 5382.42 60056.7 60056.7 50047.25 50047.25 O 5382.42 5382.42 bcbs ppo Fusion of multiple foot joints without a bone incision cpt 28730 5382.42 5382.42 5382.42 5382.42 60056.7 60056.7 50047.25 50047.25 O 5382.42 5382.42 bcbs epo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 3117.13 3117.13 bcbs hmo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 3117.13 3117.13 bcbs hmo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 3117.13 3117.13 bcbs pos Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 3117.13 3117.13 bcbs ppo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 3117.13 3117.13 bcbs epo General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2204.19 2204.19 bcbs hmo General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2204.19 2204.19 bcbs hmo General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2204.19 2204.19 bcbs pos General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2204.19 2204.19 bcbs ppo General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2204.19 2204.19 bcbs epo General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 4124.85 4124.85 bcbs hmo General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 4124.85 4124.85 bcbs hmo General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 4124.85 4124.85 bcbs pos General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 4124.85 4124.85 bcbs ppo General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 4124.85 4124.85 bcbs epo General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 2600.43 2600.43 bcbs hmo General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 2600.43 2600.43 bcbs hmo General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 2600.43 2600.43 bcbs pos General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 2600.43 2600.43 bcbs ppo General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 2600.43 2600.43 bcbs epo General revCode 720 1775.61 1775.61 613.92 613.92 7965.11 7965.11 6637.59 6637.59 O 613.92 613.92 bcbs hmo General revCode 720 1775.61 1775.61 613.92 613.92 7965.11 7965.11 6637.59 6637.59 O 613.92 613.92 bcbs hmo General revCode 720 1775.61 1775.61 613.92 613.92 7965.11 7965.11 6637.59 6637.59 O 613.92 613.92 bcbs pos General revCode 720 1775.61 1775.61 613.92 613.92 7965.11 7965.11 6637.59 6637.59 O 613.92 613.92 bcbs ppo General revCode 720 1775.61 1775.61 613.92 613.92 7965.11 7965.11 6637.59 6637.59 O 613.92 613.92 bcbs epo "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 540.19 540.19 102.7 102.7 519.73 519.73 433.11 433.11 O 540.19 540.19 bcbs hmo "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 540.19 540.19 102.7 102.7 519.73 519.73 433.11 433.11 O 540.19 540.19 bcbs hmo "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 540.19 540.19 102.7 102.7 519.73 519.73 433.11 433.11 O 540.19 540.19 bcbs pos "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 540.19 540.19 102.7 102.7 519.73 519.73 433.11 433.11 O 540.19 540.19 bcbs ppo "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 540.19 540.19 102.7 102.7 519.73 519.73 433.11 433.11 O 540.19 540.19 bcbs epo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9961.73 9961.73 bcbs hmo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9961.73 9961.73 bcbs hmo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9961.73 9961.73 bcbs pos General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9961.73 9961.73 bcbs ppo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 9961.73 9961.73 bcbs epo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 5378.65 5378.65 bcbs hmo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 5378.65 5378.65 bcbs hmo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 5378.65 5378.65 bcbs pos Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 5378.65 5378.65 bcbs ppo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 5378.65 5378.65 bcbs epo Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 5297.03 5297.03 bcbs hmo Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 5297.03 5297.03 bcbs hmo Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 5297.03 5297.03 bcbs pos Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 5297.03 5297.03 bcbs ppo Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 5297.03 5297.03 bcbs epo Partial removal of shoulder joint lining using an endoscope cpt 29820 16567.36 16567.36 16567.36 16567.36 43962.49 43962.49 36635.41 36635.41 O 16567.36 16567.36 bcbs hmo Partial removal of shoulder joint lining using an endoscope cpt 29820 16567.36 16567.36 16567.36 16567.36 43962.49 43962.49 36635.41 36635.41 O 16567.36 16567.36 bcbs hmo Partial removal of shoulder joint lining using an endoscope cpt 29820 16567.36 16567.36 16567.36 16567.36 43962.49 43962.49 36635.41 36635.41 O 16567.36 16567.36 bcbs pos Partial removal of shoulder joint lining using an endoscope cpt 29820 16567.36 16567.36 16567.36 16567.36 43962.49 43962.49 36635.41 36635.41 O 16567.36 16567.36 bcbs ppo Partial removal of shoulder joint lining using an endoscope cpt 29820 16567.36 16567.36 16567.36 16567.36 43962.49 43962.49 36635.41 36635.41 O 16567.36 16567.36 bcbs epo Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 5550.48 5550.48 bcbs hmo Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 5550.48 5550.48 bcbs hmo Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 5550.48 5550.48 bcbs pos Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 5550.48 5550.48 bcbs ppo Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 5550.48 5550.48 bcbs epo Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 3393.18 3393.18 bcbs hmo Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 3393.18 3393.18 bcbs hmo Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 3393.18 3393.18 bcbs pos Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 3393.18 3393.18 bcbs ppo Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 3393.18 3393.18 bcbs epo General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 3269.92 3269.92 bcbs hmo General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 3269.92 3269.92 bcbs hmo General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 3269.92 3269.92 bcbs pos General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 3269.92 3269.92 bcbs ppo General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 3269.92 3269.92 bcbs epo General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 3561.8 3561.8 bcbs hmo General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 3561.8 3561.8 bcbs hmo General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 3561.8 3561.8 bcbs pos General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 3561.8 3561.8 bcbs ppo General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 3561.8 3561.8 bcbs epo Stress test revCode 482 3200.73 3200.73 3200.73 3200.73 17952.22 17952.22 14960.18 14960.18 O 3200.73 3200.73 bcbs hmo Stress test revCode 482 3200.73 3200.73 3200.73 3200.73 17952.22 17952.22 14960.18 14960.18 O 3200.73 3200.73 bcbs hmo Stress test revCode 482 3200.73 3200.73 3200.73 3200.73 17952.22 17952.22 14960.18 14960.18 O 3200.73 3200.73 bcbs pos Stress test revCode 482 3200.73 3200.73 3200.73 3200.73 17952.22 17952.22 14960.18 14960.18 O 3200.73 3200.73 bcbs ppo Stress test revCode 482 3200.73 3200.73 3200.73 3200.73 17952.22 17952.22 14960.18 14960.18 O 3200.73 3200.73 bcbs epo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 9091.8 9091.8 bcbs hmo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 9091.8 9091.8 bcbs hmo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 9091.8 9091.8 bcbs pos Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 9091.8 9091.8 bcbs ppo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 9091.8 9091.8 bcbs epo Cardiac cath lab revCode 481 25638.87 25638.87 25638.87 25638.87 79574.21 79574.21 66311.84 66311.84 O 25638.87 25638.87 bcbs hmo Cardiac cath lab revCode 481 25638.87 25638.87 25638.87 25638.87 79574.21 79574.21 66311.84 66311.84 O 25638.87 25638.87 bcbs hmo Cardiac cath lab revCode 481 25638.87 25638.87 25638.87 25638.87 79574.21 79574.21 66311.84 66311.84 O 25638.87 25638.87 bcbs pos Cardiac cath lab revCode 481 25638.87 25638.87 25638.87 25638.87 79574.21 79574.21 66311.84 66311.84 O 25638.87 25638.87 bcbs ppo Cardiac cath lab revCode 481 25638.87 25638.87 25638.87 25638.87 79574.21 79574.21 66311.84 66311.84 O 25638.87 25638.87 bcbs epo General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 10836 10836 bcbs hmo General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 10836 10836 bcbs hmo General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 10836 10836 bcbs pos General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 10836 10836 bcbs ppo General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 10836 10836 bcbs epo Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 5536.39 5536.39 bcbs hmo Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 5536.39 5536.39 bcbs hmo Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 5536.39 5536.39 bcbs pos Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 5536.39 5536.39 bcbs ppo Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 5536.39 5536.39 bcbs epo General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 6950.29 6950.29 bcbs hmo General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 6950.29 6950.29 bcbs hmo General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 6950.29 6950.29 bcbs pos General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 6950.29 6950.29 bcbs ppo General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 6950.29 6950.29 bcbs epo Release or removal of shoulder scar tissue using an endoscope cpt 29825 5550.48 5550.48 2405.65 2405.65 31991.54 31991.54 26659.62 26659.62 O 5550.48 5550.48 bcbs hmo Release or removal of shoulder scar tissue using an endoscope cpt 29825 5550.48 5550.48 2405.65 2405.65 31991.54 31991.54 26659.62 26659.62 O 5550.48 5550.48 bcbs hmo Release or removal of shoulder scar tissue using an endoscope cpt 29825 5550.48 5550.48 2405.65 2405.65 31991.54 31991.54 26659.62 26659.62 O 5550.48 5550.48 bcbs pos Release or removal of shoulder scar tissue using an endoscope cpt 29825 5550.48 5550.48 2405.65 2405.65 31991.54 31991.54 26659.62 26659.62 O 5550.48 5550.48 bcbs ppo Release or removal of shoulder scar tissue using an endoscope cpt 29825 5550.48 5550.48 2405.65 2405.65 31991.54 31991.54 26659.62 26659.62 O 5550.48 5550.48 bcbs epo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1904.3 1904.3 bcbs hmo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1904.3 1904.3 bcbs hmo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1904.3 1904.3 bcbs pos General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1904.3 1904.3 bcbs ppo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1904.3 1904.3 bcbs epo Evaluation or reevaluation revCode 444 1984.88 1984.88 1984.88 1984.88 20680.18 20680.18 17233.48 17233.48 O 1984.88 1984.88 bcbs hmo Evaluation or reevaluation revCode 444 1984.88 1984.88 1984.88 1984.88 20680.18 20680.18 17233.48 17233.48 O 1984.88 1984.88 bcbs hmo Evaluation or reevaluation revCode 444 1984.88 1984.88 1984.88 1984.88 20680.18 20680.18 17233.48 17233.48 O 1984.88 1984.88 bcbs pos Evaluation or reevaluation revCode 444 1984.88 1984.88 1984.88 1984.88 20680.18 20680.18 17233.48 17233.48 O 1984.88 1984.88 bcbs ppo Evaluation or reevaluation revCode 444 1984.88 1984.88 1984.88 1984.88 20680.18 20680.18 17233.48 17233.48 O 1984.88 1984.88 bcbs epo Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 15196.01 15196.01 bcbs hmo Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 15196.01 15196.01 bcbs hmo Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 15196.01 15196.01 bcbs pos Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 15196.01 15196.01 bcbs ppo Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 15196.01 15196.01 bcbs epo Visit charge revCode 441 2154.59 2154.59 2154.59 2154.59 25292.77 25292.77 21077.31 21077.31 O 2154.59 2154.59 bcbs hmo Visit charge revCode 441 2154.59 2154.59 2154.59 2154.59 25292.77 25292.77 21077.31 21077.31 O 2154.59 2154.59 bcbs hmo Visit charge revCode 441 2154.59 2154.59 2154.59 2154.59 25292.77 25292.77 21077.31 21077.31 O 2154.59 2154.59 bcbs pos Visit charge revCode 441 2154.59 2154.59 2154.59 2154.59 25292.77 25292.77 21077.31 21077.31 O 2154.59 2154.59 bcbs ppo Visit charge revCode 441 2154.59 2154.59 2154.59 2154.59 25292.77 25292.77 21077.31 21077.31 O 2154.59 2154.59 bcbs epo General revCode 440 3038.1 3038.1 3038.1 3038.1 15181.22 15181.22 12651.02 12651.02 O 3038.1 3038.1 bcbs hmo General revCode 440 3038.1 3038.1 3038.1 3038.1 15181.22 15181.22 12651.02 12651.02 O 3038.1 3038.1 bcbs hmo General revCode 440 3038.1 3038.1 3038.1 3038.1 15181.22 15181.22 12651.02 12651.02 O 3038.1 3038.1 bcbs pos General revCode 440 3038.1 3038.1 3038.1 3038.1 15181.22 15181.22 12651.02 12651.02 O 3038.1 3038.1 bcbs ppo General revCode 440 3038.1 3038.1 3038.1 3038.1 15181.22 15181.22 12651.02 12651.02 O 3038.1 3038.1 bcbs epo Release of shoulder biceps tendon using an endoscope cpt 29828 6466.87 6466.87 5299.29 5299.29 38752.94 38752.94 32294.12 32294.12 O 6466.87 6466.87 bcbs hmo Release of shoulder biceps tendon using an endoscope cpt 29828 6466.87 6466.87 5299.29 5299.29 38752.94 38752.94 32294.12 32294.12 O 6466.87 6466.87 bcbs hmo Release of shoulder biceps tendon using an endoscope cpt 29828 6466.87 6466.87 5299.29 5299.29 38752.94 38752.94 32294.12 32294.12 O 6466.87 6466.87 bcbs pos Release of shoulder biceps tendon using an endoscope cpt 29828 6466.87 6466.87 5299.29 5299.29 38752.94 38752.94 32294.12 32294.12 O 6466.87 6466.87 bcbs ppo Release of shoulder biceps tendon using an endoscope cpt 29828 6466.87 6466.87 5299.29 5299.29 38752.94 38752.94 32294.12 32294.12 O 6466.87 6466.87 bcbs epo Irrigation and drainage of knee joint for infection using an endoscope cpt 29871 7386.83 7386.83 7386.83 7386.83 26394.78 26394.78 21995.65 21995.65 O 7386.83 7386.83 bcbs hmo Irrigation and drainage of knee joint for infection using an endoscope cpt 29871 7386.83 7386.83 7386.83 7386.83 26394.78 26394.78 21995.65 21995.65 O 7386.83 7386.83 bcbs hmo Irrigation and drainage of knee joint for infection using an endoscope cpt 29871 7386.83 7386.83 7386.83 7386.83 26394.78 26394.78 21995.65 21995.65 O 7386.83 7386.83 bcbs pos Irrigation and drainage of knee joint for infection using an endoscope cpt 29871 7386.83 7386.83 7386.83 7386.83 26394.78 26394.78 21995.65 21995.65 O 7386.83 7386.83 bcbs ppo Irrigation and drainage of knee joint for infection using an endoscope cpt 29871 7386.83 7386.83 7386.83 7386.83 26394.78 26394.78 21995.65 21995.65 O 7386.83 7386.83 bcbs epo Evaluation or reevaluation revCode 434 3544.16 3544.16 163.86 163.86 3960 3960 3300 3300 O 3544.16 3544.16 bcbs hmo Evaluation or reevaluation revCode 434 3544.16 3544.16 163.86 163.86 3960 3960 3300 3300 O 3544.16 3544.16 bcbs hmo Evaluation or reevaluation revCode 434 3544.16 3544.16 163.86 163.86 3960 3960 3300 3300 O 3544.16 3544.16 bcbs pos Evaluation or reevaluation revCode 434 3544.16 3544.16 163.86 163.86 3960 3960 3300 3300 O 3544.16 3544.16 bcbs ppo Evaluation or reevaluation revCode 434 3544.16 3544.16 163.86 163.86 3960 3960 3300 3300 O 3544.16 3544.16 bcbs epo Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1682.68 1682.68 bcbs hmo Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1682.68 1682.68 bcbs hmo Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1682.68 1682.68 bcbs pos Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1682.68 1682.68 bcbs ppo Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1682.68 1682.68 bcbs epo Partial removal of knee joint lining using an endoscope cpt 29875 5454.29 5454.29 3862.17 3862.17 24288.23 24288.23 20240.19 20240.19 O 5454.29 5454.29 bcbs hmo Partial removal of knee joint lining using an endoscope cpt 29875 5454.29 5454.29 3862.17 3862.17 24288.23 24288.23 20240.19 20240.19 O 5454.29 5454.29 bcbs hmo Partial removal of knee joint lining using an endoscope cpt 29875 5454.29 5454.29 3862.17 3862.17 24288.23 24288.23 20240.19 20240.19 O 5454.29 5454.29 bcbs pos Partial removal of knee joint lining using an endoscope cpt 29875 5454.29 5454.29 3862.17 3862.17 24288.23 24288.23 20240.19 20240.19 O 5454.29 5454.29 bcbs ppo Partial removal of knee joint lining using an endoscope cpt 29875 5454.29 5454.29 3862.17 3862.17 24288.23 24288.23 20240.19 20240.19 O 5454.29 5454.29 bcbs epo General revCode 430 5297.03 5297.03 5297.03 5297.03 51730.08 51730.08 43108.4 43108.4 O 5297.03 5297.03 bcbs hmo General revCode 430 5297.03 5297.03 5297.03 5297.03 51730.08 51730.08 43108.4 43108.4 O 5297.03 5297.03 bcbs hmo General revCode 430 5297.03 5297.03 5297.03 5297.03 51730.08 51730.08 43108.4 43108.4 O 5297.03 5297.03 bcbs pos General revCode 430 5297.03 5297.03 5297.03 5297.03 51730.08 51730.08 43108.4 43108.4 O 5297.03 5297.03 bcbs ppo General revCode 430 5297.03 5297.03 5297.03 5297.03 51730.08 51730.08 43108.4 43108.4 O 5297.03 5297.03 bcbs epo Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 1044.94 1044.94 bcbs hmo Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 1044.94 1044.94 bcbs hmo Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 1044.94 1044.94 bcbs pos Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 1044.94 1044.94 bcbs ppo Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 1044.94 1044.94 bcbs epo General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3098.67 3098.67 bcbs hmo General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3098.67 3098.67 bcbs hmo General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3098.67 3098.67 bcbs pos General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3098.67 3098.67 bcbs ppo General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3098.67 3098.67 bcbs epo Inhalation services revCode 412 3459.25 3459.25 3459.25 3459.25 19060.43 19060.43 15883.69 15883.69 O 3459.25 3459.25 bcbs hmo Inhalation services revCode 412 3459.25 3459.25 3459.25 3459.25 19060.43 19060.43 15883.69 15883.69 O 3459.25 3459.25 bcbs hmo Inhalation services revCode 412 3459.25 3459.25 3459.25 3459.25 19060.43 19060.43 15883.69 15883.69 O 3459.25 3459.25 bcbs pos Inhalation services revCode 412 3459.25 3459.25 3459.25 3459.25 19060.43 19060.43 15883.69 15883.69 O 3459.25 3459.25 bcbs ppo Inhalation services revCode 412 3459.25 3459.25 3459.25 3459.25 19060.43 19060.43 15883.69 15883.69 O 3459.25 3459.25 bcbs epo General revCode 410 2904.35 2904.35 2904.35 2904.35 17900.93 17900.93 14917.44 14917.44 O 2904.35 2904.35 bcbs hmo General revCode 410 2904.35 2904.35 2904.35 2904.35 17900.93 17900.93 14917.44 14917.44 O 2904.35 2904.35 bcbs hmo General revCode 410 2904.35 2904.35 2904.35 2904.35 17900.93 17900.93 14917.44 14917.44 O 2904.35 2904.35 bcbs pos General revCode 410 2904.35 2904.35 2904.35 2904.35 17900.93 17900.93 14917.44 14917.44 O 2904.35 2904.35 bcbs ppo General revCode 410 2904.35 2904.35 2904.35 2904.35 17900.93 17900.93 14917.44 14917.44 O 2904.35 2904.35 bcbs epo Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 1255.56 1255.56 bcbs hmo Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 1255.56 1255.56 bcbs hmo Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 1255.56 1255.56 bcbs pos Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 1255.56 1255.56 bcbs ppo Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 1255.56 1255.56 bcbs epo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 6335.66 6335.66 bcbs hmo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 6335.66 6335.66 bcbs hmo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 6335.66 6335.66 bcbs pos Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 6335.66 6335.66 bcbs ppo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 6335.66 6335.66 bcbs epo "Administration (e.g., transfusions)" revCode 391 1796.52 1796.52 1796.52 1796.52 8394 8394 6995 6995 O 1796.52 1796.52 bcbs hmo "Administration (e.g., transfusions)" revCode 391 1796.52 1796.52 1796.52 1796.52 8394 8394 6995 6995 O 1796.52 1796.52 bcbs hmo "Administration (e.g., transfusions)" revCode 391 1796.52 1796.52 1796.52 1796.52 8394 8394 6995 6995 O 1796.52 1796.52 bcbs pos "Administration (e.g., transfusions)" revCode 391 1796.52 1796.52 1796.52 1796.52 8394 8394 6995 6995 O 1796.52 1796.52 bcbs ppo "Administration (e.g., transfusions)" revCode 391 1796.52 1796.52 1796.52 1796.52 8394 8394 6995 6995 O 1796.52 1796.52 bcbs epo General revCode 390 1880.71 1880.71 1880.71 1880.71 12481.22 12481.22 10401.02 10401.02 O 1880.71 1880.71 bcbs hmo General revCode 390 1880.71 1880.71 1880.71 1880.71 12481.22 12481.22 10401.02 10401.02 O 1880.71 1880.71 bcbs hmo General revCode 390 1880.71 1880.71 1880.71 1880.71 12481.22 12481.22 10401.02 10401.02 O 1880.71 1880.71 bcbs pos General revCode 390 1880.71 1880.71 1880.71 1880.71 12481.22 12481.22 10401.02 10401.02 O 1880.71 1880.71 bcbs ppo General revCode 390 1880.71 1880.71 1880.71 1880.71 12481.22 12481.22 10401.02 10401.02 O 1880.71 1880.71 bcbs epo Incident to radiology revCode 371 22052.47 22052.47 22052.47 22052.47 66615.74 66615.74 55513.12 55513.12 O 22052.47 22052.47 bcbs hmo Incident to radiology revCode 371 22052.47 22052.47 22052.47 22052.47 66615.74 66615.74 55513.12 55513.12 O 22052.47 22052.47 bcbs hmo Incident to radiology revCode 371 22052.47 22052.47 22052.47 22052.47 66615.74 66615.74 55513.12 55513.12 O 22052.47 22052.47 bcbs pos Incident to radiology revCode 371 22052.47 22052.47 22052.47 22052.47 66615.74 66615.74 55513.12 55513.12 O 22052.47 22052.47 bcbs ppo Incident to radiology revCode 371 22052.47 22052.47 22052.47 22052.47 66615.74 66615.74 55513.12 55513.12 O 22052.47 22052.47 bcbs epo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 8866.84 8866.84 bcbs hmo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 8866.84 8866.84 bcbs hmo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 8866.84 8866.84 bcbs pos General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 8866.84 8866.84 bcbs ppo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 8866.84 8866.84 bcbs epo General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 8642.34 8642.34 bcbs hmo General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 8642.34 8642.34 bcbs hmo General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 8642.34 8642.34 bcbs pos General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 8642.34 8642.34 bcbs ppo General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 8642.34 8642.34 bcbs epo Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 2997.13 2997.13 bcbs hmo Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 2997.13 2997.13 bcbs hmo Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 2997.13 2997.13 bcbs pos Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 2997.13 2997.13 bcbs ppo Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 2997.13 2997.13 bcbs epo "Removal of polyps in nose, extensive or complex" cpt 30115 7551.65 7551.65 4819.51 4819.51 49945.48 49945.48 41621.23 41621.23 O 7551.65 7551.65 bcbs hmo "Removal of polyps in nose, extensive or complex" cpt 30115 7551.65 7551.65 4819.51 4819.51 49945.48 49945.48 41621.23 41621.23 O 7551.65 7551.65 bcbs hmo "Removal of polyps in nose, extensive or complex" cpt 30115 7551.65 7551.65 4819.51 4819.51 49945.48 49945.48 41621.23 41621.23 O 7551.65 7551.65 bcbs pos "Removal of polyps in nose, extensive or complex" cpt 30115 7551.65 7551.65 4819.51 4819.51 49945.48 49945.48 41621.23 41621.23 O 7551.65 7551.65 bcbs ppo "Removal of polyps in nose, extensive or complex" cpt 30115 7551.65 7551.65 4819.51 4819.51 49945.48 49945.48 41621.23 41621.23 O 7551.65 7551.65 bcbs epo Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 2909.63 2909.63 bcbs hmo Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 2909.63 2909.63 bcbs hmo Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 2909.63 2909.63 bcbs pos Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 2909.63 2909.63 bcbs ppo Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 2909.63 2909.63 bcbs epo General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 1916.73 1916.73 bcbs hmo General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 1916.73 1916.73 bcbs hmo General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 1916.73 1916.73 bcbs pos General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 1916.73 1916.73 bcbs ppo General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 1916.73 1916.73 bcbs epo Partial removal of nasal sinus using an endoscope cpt 31254 6790.97 6790.97 4819.51 4819.51 43785.56 43785.56 36487.97 36487.97 O 6790.97 6790.97 bcbs hmo Partial removal of nasal sinus using an endoscope cpt 31254 6790.97 6790.97 4819.51 4819.51 43785.56 43785.56 36487.97 36487.97 O 6790.97 6790.97 bcbs hmo Partial removal of nasal sinus using an endoscope cpt 31254 6790.97 6790.97 4819.51 4819.51 43785.56 43785.56 36487.97 36487.97 O 6790.97 6790.97 bcbs pos Partial removal of nasal sinus using an endoscope cpt 31254 6790.97 6790.97 4819.51 4819.51 43785.56 43785.56 36487.97 36487.97 O 6790.97 6790.97 bcbs ppo Partial removal of nasal sinus using an endoscope cpt 31254 6790.97 6790.97 4819.51 4819.51 43785.56 43785.56 36487.97 36487.97 O 6790.97 6790.97 bcbs epo "Removal of nasal sinus tissue using an endoscope, maxillary sinus" cpt 31267 6790.97 6790.97 4819.51 4819.51 34277.41 34277.41 28564.51 28564.51 O 6790.97 6790.97 bcbs hmo "Removal of nasal sinus tissue using an endoscope, maxillary sinus" cpt 31267 6790.97 6790.97 4819.51 4819.51 34277.41 34277.41 28564.51 28564.51 O 6790.97 6790.97 bcbs hmo "Removal of nasal sinus tissue using an endoscope, maxillary sinus" cpt 31267 6790.97 6790.97 4819.51 4819.51 34277.41 34277.41 28564.51 28564.51 O 6790.97 6790.97 bcbs pos "Removal of nasal sinus tissue using an endoscope, maxillary sinus" cpt 31267 6790.97 6790.97 4819.51 4819.51 34277.41 34277.41 28564.51 28564.51 O 6790.97 6790.97 bcbs ppo "Removal of nasal sinus tissue using an endoscope, maxillary sinus" cpt 31267 6790.97 6790.97 4819.51 4819.51 34277.41 34277.41 28564.51 28564.51 O 6790.97 6790.97 bcbs epo Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 3200.73 3200.73 bcbs hmo Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 3200.73 3200.73 bcbs hmo Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 3200.73 3200.73 bcbs pos Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 3200.73 3200.73 bcbs ppo Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 3200.73 3200.73 bcbs epo Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3200.73 3200.73 bcbs hmo Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3200.73 3200.73 bcbs hmo Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3200.73 3200.73 bcbs pos Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3200.73 3200.73 bcbs ppo Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3200.73 3200.73 bcbs epo Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 3913.9 3913.9 bcbs hmo Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 3913.9 3913.9 bcbs hmo Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 3913.9 3913.9 bcbs pos Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 3913.9 3913.9 bcbs ppo Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 3913.9 3913.9 bcbs epo Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 2756.03 2756.03 bcbs hmo Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 2756.03 2756.03 bcbs hmo Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 2756.03 2756.03 bcbs pos Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 2756.03 2756.03 bcbs ppo Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 2756.03 2756.03 bcbs epo Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3576.75 3576.75 bcbs hmo Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3576.75 3576.75 bcbs hmo Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3576.75 3576.75 bcbs pos Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3576.75 3576.75 bcbs ppo Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3576.75 3576.75 bcbs epo Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 2899.33 2899.33 bcbs hmo Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 2899.33 2899.33 bcbs hmo Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 2899.33 2899.33 bcbs pos Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 2899.33 2899.33 bcbs ppo Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 2899.33 2899.33 bcbs epo General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 6718.4 6718.4 bcbs hmo General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 6718.4 6718.4 bcbs hmo General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 6718.4 6718.4 bcbs pos General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 6718.4 6718.4 bcbs ppo General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 6718.4 6718.4 bcbs epo Histology revCode 312 1249.79 1249.79 1249.79 1249.79 5404.87 5404.87 4504.06 4504.06 O 1249.79 1249.79 bcbs hmo Histology revCode 312 1249.79 1249.79 1249.79 1249.79 5404.87 5404.87 4504.06 4504.06 O 1249.79 1249.79 bcbs hmo Histology revCode 312 1249.79 1249.79 1249.79 1249.79 5404.87 5404.87 4504.06 4504.06 O 1249.79 1249.79 bcbs pos Histology revCode 312 1249.79 1249.79 1249.79 1249.79 5404.87 5404.87 4504.06 4504.06 O 1249.79 1249.79 bcbs ppo Histology revCode 312 1249.79 1249.79 1249.79 1249.79 5404.87 5404.87 4504.06 4504.06 O 1249.79 1249.79 bcbs epo General revCode 310 8642.34 8642.34 1829.25 1829.25 24781.55 24781.55 20651.29 20651.29 O 8642.34 8642.34 bcbs hmo General revCode 310 8642.34 8642.34 1829.25 1829.25 24781.55 24781.55 20651.29 20651.29 O 8642.34 8642.34 bcbs hmo General revCode 310 8642.34 8642.34 1829.25 1829.25 24781.55 24781.55 20651.29 20651.29 O 8642.34 8642.34 bcbs pos General revCode 310 8642.34 8642.34 1829.25 1829.25 24781.55 24781.55 20651.29 20651.29 O 8642.34 8642.34 bcbs ppo General revCode 310 8642.34 8642.34 1829.25 1829.25 24781.55 24781.55 20651.29 20651.29 O 8642.34 8642.34 bcbs epo Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 3532.41 3532.41 bcbs hmo Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 3532.41 3532.41 bcbs hmo Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 3532.41 3532.41 bcbs pos Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 3532.41 3532.41 bcbs ppo Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 3532.41 3532.41 bcbs epo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 3043.23 3043.23 bcbs hmo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 3043.23 3043.23 bcbs hmo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 3043.23 3043.23 bcbs pos General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 3043.23 3043.23 bcbs ppo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 3043.23 3043.23 bcbs epo General revCode 280 3034.45 3034.45 3034.45 3034.45 12935.92 12935.92 10779.93 10779.93 O 3034.45 3034.45 bcbs hmo General revCode 280 3034.45 3034.45 3034.45 3034.45 12935.92 12935.92 10779.93 10779.93 O 3034.45 3034.45 bcbs hmo General revCode 280 3034.45 3034.45 3034.45 3034.45 12935.92 12935.92 10779.93 10779.93 O 3034.45 3034.45 bcbs pos General revCode 280 3034.45 3034.45 3034.45 3034.45 12935.92 12935.92 10779.93 10779.93 O 3034.45 3034.45 bcbs ppo General revCode 280 3034.45 3034.45 3034.45 3034.45 12935.92 12935.92 10779.93 10779.93 O 3034.45 3034.45 bcbs epo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 13825.2 13825.2 bcbs hmo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 13825.2 13825.2 bcbs hmo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 13825.2 13825.2 bcbs pos Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 13825.2 13825.2 bcbs ppo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 13825.2 13825.2 bcbs epo Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 13825.2 13825.2 bcbs hmo Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 13825.2 13825.2 bcbs hmo Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 13825.2 13825.2 bcbs pos Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 13825.2 13825.2 bcbs ppo Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 13825.2 13825.2 bcbs epo "Removal and replacement of defibrillator pulse generator, multiple wires (leads)" cpt 33264 28598.55 28598.55 19829.15 19829.15 91681.37 91681.37 76401.14 76401.14 O 19829.15 19829.15 bcbs hmo "Removal and replacement of defibrillator pulse generator, multiple wires (leads)" cpt 33264 28598.55 28598.55 19829.15 19829.15 91681.37 91681.37 76401.14 76401.14 O 19829.15 19829.15 bcbs hmo "Removal and replacement of defibrillator pulse generator, multiple wires (leads)" cpt 33264 28598.55 28598.55 19829.15 19829.15 91681.37 91681.37 76401.14 76401.14 O 19829.15 19829.15 bcbs pos "Removal and replacement of defibrillator pulse generator, multiple wires (leads)" cpt 33264 28598.55 28598.55 19829.15 19829.15 91681.37 91681.37 76401.14 76401.14 O 19829.15 19829.15 bcbs ppo "Removal and replacement of defibrillator pulse generator, multiple wires (leads)" cpt 33264 28598.55 28598.55 19829.15 19829.15 91681.37 91681.37 76401.14 76401.14 O 19829.15 19829.15 bcbs epo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3525.48 3525.48 bcbs hmo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3525.48 3525.48 bcbs hmo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3525.48 3525.48 bcbs pos General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3525.48 3525.48 bcbs ppo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3525.48 3525.48 bcbs epo Insertion of catheter into artery on one side of chest for diagnosis or treatment including radiological supervision and interpretation cpt 36225 5763.06 5763.06 3779.86 3779.86 16929.42 16929.42 14107.85 14107.85 O 5763.06 5763.06 bcbs hmo Insertion of catheter into artery on one side of chest for diagnosis or treatment including radiological supervision and interpretation cpt 36225 5763.06 5763.06 3779.86 3779.86 16929.42 16929.42 14107.85 14107.85 O 5763.06 5763.06 bcbs hmo Insertion of catheter into artery on one side of chest for diagnosis or treatment including radiological supervision and interpretation cpt 36225 5763.06 5763.06 3779.86 3779.86 16929.42 16929.42 14107.85 14107.85 O 5763.06 5763.06 bcbs pos Insertion of catheter into artery on one side of chest for diagnosis or treatment including radiological supervision and interpretation cpt 36225 5763.06 5763.06 3779.86 3779.86 16929.42 16929.42 14107.85 14107.85 O 5763.06 5763.06 bcbs ppo Insertion of catheter into artery on one side of chest for diagnosis or treatment including radiological supervision and interpretation cpt 36225 5763.06 5763.06 3779.86 3779.86 16929.42 16929.42 14107.85 14107.85 O 5763.06 5763.06 bcbs epo General revCode 260 5297.03 5297.03 5297.03 5297.03 16233.73 16233.73 13528.11 13528.11 O 5297.03 5297.03 bcbs hmo General revCode 260 5297.03 5297.03 5297.03 5297.03 16233.73 16233.73 13528.11 13528.11 O 5297.03 5297.03 bcbs hmo General revCode 260 5297.03 5297.03 5297.03 5297.03 16233.73 16233.73 13528.11 13528.11 O 5297.03 5297.03 bcbs pos General revCode 260 5297.03 5297.03 5297.03 5297.03 16233.73 16233.73 13528.11 13528.11 O 5297.03 5297.03 bcbs ppo General revCode 260 5297.03 5297.03 5297.03 5297.03 16233.73 16233.73 13528.11 13528.11 O 5297.03 5297.03 bcbs epo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 9091.33 9091.33 bcbs hmo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 9091.33 9091.33 bcbs hmo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 9091.33 9091.33 bcbs pos IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 9091.33 9091.33 bcbs ppo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 9091.33 9091.33 bcbs epo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5809.49 5809.49 bcbs hmo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5809.49 5809.49 bcbs hmo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5809.49 5809.49 bcbs pos transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5809.49 5809.49 bcbs ppo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5809.49 5809.49 bcbs epo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 3043.23 3043.23 bcbs hmo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 3043.23 3043.23 bcbs hmo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 3043.23 3043.23 bcbs pos General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 3043.23 3043.23 bcbs ppo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 3043.23 3043.23 bcbs epo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 2579.59 2579.59 bcbs hmo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 2579.59 2579.59 bcbs hmo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 2579.59 2579.59 bcbs pos post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 2579.59 2579.59 bcbs ppo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 2579.59 2579.59 bcbs epo contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 4337.53 4337.53 bcbs hmo contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 4337.53 4337.53 bcbs hmo contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 4337.53 4337.53 bcbs pos contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 4337.53 4337.53 bcbs ppo contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 4337.53 4337.53 bcbs epo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 7599.47 7599.47 bcbs hmo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 7599.47 7599.47 bcbs hmo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 7599.47 7599.47 bcbs pos robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 7599.47 7599.47 bcbs ppo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 7599.47 7599.47 bcbs epo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 6037.32 6037.32 bcbs hmo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 6037.32 6037.32 bcbs hmo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 6037.32 6037.32 bcbs pos "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 6037.32 6037.32 bcbs ppo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 6037.32 6037.32 bcbs epo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 13720.75 13720.75 bcbs hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 13720.75 13720.75 bcbs hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 13720.75 13720.75 bcbs pos intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 13720.75 13720.75 bcbs ppo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 13720.75 13720.75 bcbs epo visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 3874.3 3874.3 bcbs hmo visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 3874.3 3874.3 bcbs hmo visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 3874.3 3874.3 bcbs pos visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 3874.3 3874.3 bcbs ppo visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 3874.3 3874.3 bcbs epo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 116.97 116.97 bcbs hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 116.97 116.97 bcbs hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 116.97 116.97 bcbs pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 116.97 116.97 bcbs ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 116.97 116.97 bcbs epo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 877.03 877.03 bcbs hmo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 877.03 877.03 bcbs hmo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 877.03 877.03 bcbs pos "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 877.03 877.03 bcbs ppo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 877.03 877.03 bcbs epo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10872.3 10872.3 bcbs hmo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10872.3 10872.3 bcbs hmo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10872.3 10872.3 bcbs pos "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10872.3 10872.3 bcbs ppo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10872.3 10872.3 bcbs epo inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 8152.79 8152.79 bcbs hmo inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 8152.79 8152.79 bcbs hmo inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 8152.79 8152.79 bcbs pos inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 8152.79 8152.79 bcbs ppo inj mvasi 10 mg cpt Q5107 8152.79 8152.79 376.97 376.97 23673.43 23673.43 19727.86 19727.86 O 8152.79 8152.79 bcbs epo apligraf cpt Q4101 2485.7 2485.7 1437.55 1437.55 20100.16 20100.16 16750.13 16750.13 O 2485.7 2485.7 bcbs hmo apligraf cpt Q4101 2485.7 2485.7 1437.55 1437.55 20100.16 20100.16 16750.13 16750.13 O 2485.7 2485.7 bcbs hmo apligraf cpt Q4101 2485.7 2485.7 1437.55 1437.55 20100.16 20100.16 16750.13 16750.13 O 2485.7 2485.7 bcbs pos apligraf cpt Q4101 2485.7 2485.7 1437.55 1437.55 20100.16 20100.16 16750.13 16750.13 O 2485.7 2485.7 bcbs ppo apligraf cpt Q4101 2485.7 2485.7 1437.55 1437.55 20100.16 20100.16 16750.13 16750.13 O 2485.7 2485.7 bcbs epo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 801.75 801.75 bcbs hmo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 801.75 801.75 bcbs hmo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 801.75 801.75 bcbs pos "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 801.75 801.75 bcbs ppo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 801.75 801.75 bcbs epo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 2209.95 2209.95 bcbs hmo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 2209.95 2209.95 bcbs hmo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 2209.95 2209.95 bcbs pos rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 2209.95 2209.95 bcbs ppo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 2209.95 2209.95 bcbs epo plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 2178.24 2178.24 bcbs hmo plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 2178.24 2178.24 bcbs hmo plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 2178.24 2178.24 bcbs pos plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 2178.24 2178.24 bcbs ppo plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 2178.24 2178.24 bcbs epo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1751.84 1751.84 bcbs hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1751.84 1751.84 bcbs hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1751.84 1751.84 bcbs pos Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1751.84 1751.84 bcbs ppo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1751.84 1751.84 bcbs epo platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 2178.24 2178.24 bcbs hmo platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 2178.24 2178.24 bcbs hmo platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 2178.24 2178.24 bcbs pos platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 2178.24 2178.24 bcbs ppo platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 2178.24 2178.24 bcbs epo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 2337.61 2337.61 bcbs hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 2337.61 2337.61 bcbs hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 2337.61 2337.61 bcbs pos rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 2337.61 2337.61 bcbs ppo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 2337.61 2337.61 bcbs epo implt neurostim elctr each cpt L8680 8962.99 8962.99 8962.99 8962.99 15490.97 15490.97 12909.14 12909.14 O 8962.99 8962.99 bcbs hmo implt neurostim elctr each cpt L8680 8962.99 8962.99 8962.99 8962.99 15490.97 15490.97 12909.14 12909.14 O 8962.99 8962.99 bcbs hmo implt neurostim elctr each cpt L8680 8962.99 8962.99 8962.99 8962.99 15490.97 15490.97 12909.14 12909.14 O 8962.99 8962.99 bcbs pos implt neurostim elctr each cpt L8680 8962.99 8962.99 8962.99 8962.99 15490.97 15490.97 12909.14 12909.14 O 8962.99 8962.99 bcbs ppo implt neurostim elctr each cpt L8680 8962.99 8962.99 8962.99 8962.99 15490.97 15490.97 12909.14 12909.14 O 8962.99 8962.99 bcbs epo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 2178.24 2178.24 bcbs hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 2178.24 2178.24 bcbs hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 2178.24 2178.24 bcbs pos Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 2178.24 2178.24 bcbs ppo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 2178.24 2178.24 bcbs epo non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 529.29 529.29 bcbs hmo non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 529.29 529.29 bcbs hmo non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 529.29 529.29 bcbs pos non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 529.29 529.29 bcbs ppo non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 529.29 529.29 bcbs epo so acro/clav can web pre ots cpt L3670 16498.51 16498.51 5299.29 5299.29 37379.68 37379.68 31149.73 31149.73 O 16498.51 16498.51 bcbs hmo so acro/clav can web pre ots cpt L3670 16498.51 16498.51 5299.29 5299.29 37379.68 37379.68 31149.73 31149.73 O 16498.51 16498.51 bcbs hmo so acro/clav can web pre ots cpt L3670 16498.51 16498.51 5299.29 5299.29 37379.68 37379.68 31149.73 31149.73 O 16498.51 16498.51 bcbs pos so acro/clav can web pre ots cpt L3670 16498.51 16498.51 5299.29 5299.29 37379.68 37379.68 31149.73 31149.73 O 16498.51 16498.51 bcbs ppo so acro/clav can web pre ots cpt L3670 16498.51 16498.51 5299.29 5299.29 37379.68 37379.68 31149.73 31149.73 O 16498.51 16498.51 bcbs epo so 8 ab rstr can/web pre ots cpt L3660 9596.97 9596.97 4859.91 4859.91 40126.92 40126.92 33439.1 33439.1 O 9596.97 9596.97 bcbs hmo so 8 ab rstr can/web pre ots cpt L3660 9596.97 9596.97 4859.91 4859.91 40126.92 40126.92 33439.1 33439.1 O 9596.97 9596.97 bcbs hmo so 8 ab rstr can/web pre ots cpt L3660 9596.97 9596.97 4859.91 4859.91 40126.92 40126.92 33439.1 33439.1 O 9596.97 9596.97 bcbs pos so 8 ab rstr can/web pre ots cpt L3660 9596.97 9596.97 4859.91 4859.91 40126.92 40126.92 33439.1 33439.1 O 9596.97 9596.97 bcbs ppo so 8 ab rstr can/web pre ots cpt L3660 9596.97 9596.97 4859.91 4859.91 40126.92 40126.92 33439.1 33439.1 O 9596.97 9596.97 bcbs epo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 572.85 572.85 bcbs hmo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 572.85 572.85 bcbs hmo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 572.85 572.85 bcbs pos ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 572.85 572.85 bcbs ppo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 572.85 572.85 bcbs epo Injection of chemical agent into multiple incompetent veins of one leg cpt 36471 12086.89 12086.89 240.32 240.32 499.13 499.13 415.94 415.94 O 12086.89 12086.89 bcbs hmo Injection of chemical agent into multiple incompetent veins of one leg cpt 36471 12086.89 12086.89 240.32 240.32 499.13 499.13 415.94 415.94 O 12086.89 12086.89 bcbs hmo Injection of chemical agent into multiple incompetent veins of one leg cpt 36471 12086.89 12086.89 240.32 240.32 499.13 499.13 415.94 415.94 O 12086.89 12086.89 bcbs pos Injection of chemical agent into multiple incompetent veins of one leg cpt 36471 12086.89 12086.89 240.32 240.32 499.13 499.13 415.94 415.94 O 12086.89 12086.89 bcbs ppo Injection of chemical agent into multiple incompetent veins of one leg cpt 36471 12086.89 12086.89 240.32 240.32 499.13 499.13 415.94 415.94 O 12086.89 12086.89 bcbs epo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 10340.17 10340.17 bcbs hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 10340.17 10340.17 bcbs hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 10340.17 10340.17 bcbs pos "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 10340.17 10340.17 bcbs ppo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 10340.17 10340.17 bcbs epo "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 12086.89 12086.89 bcbs hmo "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 12086.89 12086.89 bcbs hmo "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 12086.89 12086.89 bcbs pos "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 12086.89 12086.89 bcbs ppo "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 12086.89 12086.89 bcbs epo inj trastuzumab excl biosimi cpt J9355 11920.99 11920.99 4839.22 4839.22 26839.2 26839.2 22366 22366 O 8614.56 8614.56 bcbs hmo inj trastuzumab excl biosimi cpt J9355 11920.99 11920.99 4839.22 4839.22 26839.2 26839.2 22366 22366 O 8614.56 8614.56 bcbs hmo inj trastuzumab excl biosimi cpt J9355 11920.99 11920.99 4839.22 4839.22 26839.2 26839.2 22366 22366 O 8614.56 8614.56 bcbs pos inj trastuzumab excl biosimi cpt J9355 11920.99 11920.99 4839.22 4839.22 26839.2 26839.2 22366 22366 O 8614.56 8614.56 bcbs ppo inj trastuzumab excl biosimi cpt J9355 11920.99 11920.99 4839.22 4839.22 26839.2 26839.2 22366 22366 O 8614.56 8614.56 bcbs epo "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 16776.17 16776.17 bcbs hmo "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 16776.17 16776.17 bcbs hmo "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 16776.17 16776.17 bcbs pos "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 16776.17 16776.17 bcbs ppo "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 16776.17 16776.17 bcbs epo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 4400.88 4400.88 bcbs hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 4400.88 4400.88 bcbs hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 4400.88 4400.88 bcbs pos "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 4400.88 4400.88 bcbs ppo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 4400.88 4400.88 bcbs epo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 4264.13 4264.13 bcbs hmo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 4264.13 4264.13 bcbs hmo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 4264.13 4264.13 bcbs pos "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 4264.13 4264.13 bcbs ppo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 4264.13 4264.13 bcbs epo "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 11042.46 11042.46 bcbs hmo "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 11042.46 11042.46 bcbs hmo "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 11042.46 11042.46 bcbs pos "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 11042.46 11042.46 bcbs ppo "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 11042.46 11042.46 bcbs epo inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 17466.44 17466.44 bcbs hmo inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 17466.44 17466.44 bcbs hmo inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 17466.44 17466.44 bcbs pos inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 17466.44 17466.44 bcbs ppo inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 17466.44 17466.44 bcbs epo panitumumab injection cpt J9303 6492.39 6492.39 5037.32 5037.32 28415.21 28415.21 23679.34 23679.34 O 6492.39 6492.39 bcbs hmo panitumumab injection cpt J9303 6492.39 6492.39 5037.32 5037.32 28415.21 28415.21 23679.34 23679.34 O 6492.39 6492.39 bcbs hmo panitumumab injection cpt J9303 6492.39 6492.39 5037.32 5037.32 28415.21 28415.21 23679.34 23679.34 O 6492.39 6492.39 bcbs pos panitumumab injection cpt J9303 6492.39 6492.39 5037.32 5037.32 28415.21 28415.21 23679.34 23679.34 O 6492.39 6492.39 bcbs ppo panitumumab injection cpt J9303 6492.39 6492.39 5037.32 5037.32 28415.21 28415.21 23679.34 23679.34 O 6492.39 6492.39 bcbs epo "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 3788.28 3788.28 bcbs hmo "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 3788.28 3788.28 bcbs hmo "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 3788.28 3788.28 bcbs pos "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 3788.28 3788.28 bcbs ppo "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 3788.28 3788.28 bcbs epo "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 4695.23 4695.23 bcbs hmo "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 4695.23 4695.23 bcbs hmo "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 4695.23 4695.23 bcbs pos "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 4695.23 4695.23 bcbs ppo "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 4695.23 4695.23 bcbs epo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 8596.32 8596.32 bcbs hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 8596.32 8596.32 bcbs hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 8596.32 8596.32 bcbs pos inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 8596.32 8596.32 bcbs ppo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 8596.32 8596.32 bcbs epo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 834 834 bcbs hmo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 834 834 bcbs hmo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 834 834 bcbs pos paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 834 834 bcbs ppo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 834 834 bcbs epo MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 978.69 978.69 bcbs hmo MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 978.69 978.69 bcbs hmo MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 978.69 978.69 bcbs pos MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 978.69 978.69 bcbs ppo MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 978.69 978.69 bcbs epo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 2702.31 2702.31 bcbs hmo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 2702.31 2702.31 bcbs hmo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 2702.31 2702.31 bcbs pos paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 2702.31 2702.31 bcbs ppo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 2702.31 2702.31 bcbs epo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4967.42 4967.42 bcbs hmo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4967.42 4967.42 bcbs hmo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4967.42 4967.42 bcbs pos oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4967.42 4967.42 bcbs ppo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4967.42 4967.42 bcbs epo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 1036.13 1036.13 bcbs hmo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 1036.13 1036.13 bcbs hmo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 1036.13 1036.13 bcbs pos methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 1036.13 1036.13 bcbs ppo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 1036.13 1036.13 bcbs epo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 925.72 925.72 bcbs hmo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 925.72 925.72 bcbs hmo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 925.72 925.72 bcbs pos leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 925.72 925.72 bcbs ppo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 925.72 925.72 bcbs epo irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 1106.07 1106.07 bcbs hmo irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 1106.07 1106.07 bcbs hmo irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 1106.07 1106.07 bcbs pos irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 1106.07 1106.07 bcbs ppo irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 1106.07 1106.07 bcbs epo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 4465.16 4465.16 bcbs hmo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 4465.16 4465.16 bcbs hmo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 4465.16 4465.16 bcbs pos in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 4465.16 4465.16 bcbs ppo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 4465.16 4465.16 bcbs epo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 1085.71 1085.71 bcbs hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 1085.71 1085.71 bcbs hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 1085.71 1085.71 bcbs pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 1085.71 1085.71 bcbs ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 1085.71 1085.71 bcbs epo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4478.69 4478.69 bcbs hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4478.69 4478.69 bcbs hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4478.69 4478.69 bcbs pos fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4478.69 4478.69 bcbs ppo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4478.69 4478.69 bcbs epo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 3237.54 3237.54 bcbs hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 3237.54 3237.54 bcbs hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 3237.54 3237.54 bcbs pos Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 3237.54 3237.54 bcbs ppo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 3237.54 3237.54 bcbs epo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 299.23 299.23 bcbs hmo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 299.23 299.23 bcbs hmo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 299.23 299.23 bcbs pos etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 299.23 299.23 bcbs ppo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 299.23 299.23 bcbs epo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 2537.15 2537.15 bcbs hmo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 2537.15 2537.15 bcbs hmo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 2537.15 2537.15 bcbs pos eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 2537.15 2537.15 bcbs ppo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 2537.15 2537.15 bcbs epo "inj., durvalumab, 10 mg" cpt J9173 5773.32 5773.32 2992.06 2992.06 10534.7 10534.7 8778.92 8778.92 O 3900.94 3900.94 bcbs hmo "inj., durvalumab, 10 mg" cpt J9173 5773.32 5773.32 2992.06 2992.06 10534.7 10534.7 8778.92 8778.92 O 3900.94 3900.94 bcbs hmo "inj., durvalumab, 10 mg" cpt J9173 5773.32 5773.32 2992.06 2992.06 10534.7 10534.7 8778.92 8778.92 O 3900.94 3900.94 bcbs pos "inj., durvalumab, 10 mg" cpt J9173 5773.32 5773.32 2992.06 2992.06 10534.7 10534.7 8778.92 8778.92 O 3900.94 3900.94 bcbs ppo "inj., durvalumab, 10 mg" cpt J9173 5773.32 5773.32 2992.06 2992.06 10534.7 10534.7 8778.92 8778.92 O 3900.94 3900.94 bcbs epo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 434.81 434.81 bcbs hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 434.81 434.81 bcbs hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 434.81 434.81 bcbs pos Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 434.81 434.81 bcbs ppo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 434.81 434.81 bcbs epo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 21516.54 21516.54 bcbs hmo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 21516.54 21516.54 bcbs hmo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 21516.54 21516.54 bcbs pos docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 21516.54 21516.54 bcbs ppo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 21516.54 21516.54 bcbs epo "Relocation of arm vein with connection to arm artery, open procedure, upper arm, cephalic vein" cpt 36818 7503.88 7503.88 4006.52 4006.52 19449.97 19449.97 16208.31 16208.31 O 7503.88 7503.88 bcbs hmo "Relocation of arm vein with connection to arm artery, open procedure, upper arm, cephalic vein" cpt 36818 7503.88 7503.88 4006.52 4006.52 19449.97 19449.97 16208.31 16208.31 O 7503.88 7503.88 bcbs hmo "Relocation of arm vein with connection to arm artery, open procedure, upper arm, cephalic vein" cpt 36818 7503.88 7503.88 4006.52 4006.52 19449.97 19449.97 16208.31 16208.31 O 7503.88 7503.88 bcbs pos "Relocation of arm vein with connection to arm artery, open procedure, upper arm, cephalic vein" cpt 36818 7503.88 7503.88 4006.52 4006.52 19449.97 19449.97 16208.31 16208.31 O 7503.88 7503.88 bcbs ppo "Relocation of arm vein with connection to arm artery, open procedure, upper arm, cephalic vein" cpt 36818 7503.88 7503.88 4006.52 4006.52 19449.97 19449.97 16208.31 16208.31 O 7503.88 7503.88 bcbs epo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 3343.78 3343.78 bcbs hmo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 3343.78 3343.78 bcbs hmo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 3343.78 3343.78 bcbs pos cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 3343.78 3343.78 bcbs ppo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 3343.78 3343.78 bcbs epo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 1362.97 1362.97 bcbs hmo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 1362.97 1362.97 bcbs hmo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 1362.97 1362.97 bcbs pos cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 1362.97 1362.97 bcbs ppo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 1362.97 1362.97 bcbs epo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 1629.98 1629.98 bcbs hmo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 1629.98 1629.98 bcbs hmo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 1629.98 1629.98 bcbs pos carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 1629.98 1629.98 bcbs ppo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 1629.98 1629.98 bcbs epo brentuximab vedotin inj cpt J9042 28140.84 28140.84 25901.14 25901.14 105462.79 105462.79 87885.66 87885.66 O 28140.84 28140.84 bcbs hmo brentuximab vedotin inj cpt J9042 28140.84 28140.84 25901.14 25901.14 105462.79 105462.79 87885.66 87885.66 O 28140.84 28140.84 bcbs hmo brentuximab vedotin inj cpt J9042 28140.84 28140.84 25901.14 25901.14 105462.79 105462.79 87885.66 87885.66 O 28140.84 28140.84 bcbs pos brentuximab vedotin inj cpt J9042 28140.84 28140.84 25901.14 25901.14 105462.79 105462.79 87885.66 87885.66 O 28140.84 28140.84 bcbs ppo brentuximab vedotin inj cpt J9042 28140.84 28140.84 25901.14 25901.14 105462.79 105462.79 87885.66 87885.66 O 28140.84 28140.84 bcbs epo "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8539.57 8539.57 bcbs hmo "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8539.57 8539.57 bcbs hmo "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8539.57 8539.57 bcbs pos "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8539.57 8539.57 bcbs ppo "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8539.57 8539.57 bcbs epo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 4353.14 4353.14 bcbs hmo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 4353.14 4353.14 bcbs hmo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 4353.14 4353.14 bcbs pos bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 4353.14 4353.14 bcbs ppo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 4353.14 4353.14 bcbs epo azacitidine injection cpt J9025 10639.2 10639.2 1384.01 1384.01 18628.44 18628.44 15523.7 15523.7 O 10639.2 10639.2 bcbs hmo azacitidine injection cpt J9025 10639.2 10639.2 1384.01 1384.01 18628.44 18628.44 15523.7 15523.7 O 10639.2 10639.2 bcbs hmo azacitidine injection cpt J9025 10639.2 10639.2 1384.01 1384.01 18628.44 18628.44 15523.7 15523.7 O 10639.2 10639.2 bcbs pos azacitidine injection cpt J9025 10639.2 10639.2 1384.01 1384.01 18628.44 18628.44 15523.7 15523.7 O 10639.2 10639.2 bcbs ppo azacitidine injection cpt J9025 10639.2 10639.2 1384.01 1384.01 18628.44 18628.44 15523.7 15523.7 O 10639.2 10639.2 bcbs epo doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 3343.78 3343.78 bcbs hmo doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 3343.78 3343.78 bcbs hmo doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 3343.78 3343.78 bcbs pos doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 3343.78 3343.78 bcbs ppo doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 3343.78 3343.78 bcbs epo oral aprepitant cpt J8501 3731.15 3731.15 3688.73 3688.73 23183 23183 19319.17 19319.17 O 3731.15 3731.15 bcbs hmo oral aprepitant cpt J8501 3731.15 3731.15 3688.73 3688.73 23183 23183 19319.17 19319.17 O 3731.15 3731.15 bcbs hmo oral aprepitant cpt J8501 3731.15 3731.15 3688.73 3688.73 23183 23183 19319.17 19319.17 O 3731.15 3731.15 bcbs pos oral aprepitant cpt J8501 3731.15 3731.15 3688.73 3688.73 23183 23183 19319.17 19319.17 O 3731.15 3731.15 bcbs ppo oral aprepitant cpt J8501 3731.15 3731.15 3688.73 3688.73 23183 23183 19319.17 19319.17 O 3731.15 3731.15 bcbs epo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 652.36 652.36 bcbs hmo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 652.36 652.36 bcbs hmo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 652.36 652.36 bcbs pos prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 652.36 652.36 bcbs ppo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 652.36 652.36 bcbs epo 5% dextrose in lac ringers cpt J7121 1369.1 1369.1 149.16 149.16 3793.86 3793.86 3161.55 3161.55 O 802.27 802.27 bcbs hmo 5% dextrose in lac ringers cpt J7121 1369.1 1369.1 149.16 149.16 3793.86 3793.86 3161.55 3161.55 O 802.27 802.27 bcbs hmo 5% dextrose in lac ringers cpt J7121 1369.1 1369.1 149.16 149.16 3793.86 3793.86 3161.55 3161.55 O 802.27 802.27 bcbs pos 5% dextrose in lac ringers cpt J7121 1369.1 1369.1 149.16 149.16 3793.86 3793.86 3161.55 3161.55 O 802.27 802.27 bcbs ppo 5% dextrose in lac ringers cpt J7121 1369.1 1369.1 149.16 149.16 3793.86 3793.86 3161.55 3161.55 O 802.27 802.27 bcbs epo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4018.73 4018.73 bcbs hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4018.73 4018.73 bcbs hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4018.73 4018.73 bcbs pos ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4018.73 4018.73 bcbs ppo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4018.73 4018.73 bcbs epo normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 1137.02 1137.02 bcbs hmo normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 1137.02 1137.02 bcbs hmo normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 1137.02 1137.02 bcbs pos normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 1137.02 1137.02 bcbs ppo normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 1137.02 1137.02 bcbs epo 5% dextrose/normal saline cpt J7042 3569.24 3569.24 571.3 571.3 5614.46 5614.46 4678.72 4678.72 O 3569.24 3569.24 bcbs hmo 5% dextrose/normal saline cpt J7042 3569.24 3569.24 571.3 571.3 5614.46 5614.46 4678.72 4678.72 O 3569.24 3569.24 bcbs hmo 5% dextrose/normal saline cpt J7042 3569.24 3569.24 571.3 571.3 5614.46 5614.46 4678.72 4678.72 O 3569.24 3569.24 bcbs pos 5% dextrose/normal saline cpt J7042 3569.24 3569.24 571.3 571.3 5614.46 5614.46 4678.72 4678.72 O 3569.24 3569.24 bcbs ppo 5% dextrose/normal saline cpt J7042 3569.24 3569.24 571.3 571.3 5614.46 5614.46 4678.72 4678.72 O 3569.24 3569.24 bcbs epo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1497.07 1497.07 bcbs hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1497.07 1497.07 bcbs hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1497.07 1497.07 bcbs pos normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1497.07 1497.07 bcbs ppo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1497.07 1497.07 bcbs epo "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 12086.89 12086.89 bcbs hmo "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 12086.89 12086.89 bcbs hmo "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 12086.89 12086.89 bcbs pos "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 12086.89 12086.89 bcbs ppo "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 12086.89 12086.89 bcbs epo Blood vessel procedure cpt 37799 12086.89 12086.89 12086.89 12086.89 25953.26 25953.26 21627.72 21627.72 O 12086.89 12086.89 bcbs hmo Blood vessel procedure cpt 37799 12086.89 12086.89 12086.89 12086.89 25953.26 25953.26 21627.72 21627.72 O 12086.89 12086.89 bcbs hmo Blood vessel procedure cpt 37799 12086.89 12086.89 12086.89 12086.89 25953.26 25953.26 21627.72 21627.72 O 12086.89 12086.89 bcbs pos Blood vessel procedure cpt 37799 12086.89 12086.89 12086.89 12086.89 25953.26 25953.26 21627.72 21627.72 O 12086.89 12086.89 bcbs ppo Blood vessel procedure cpt 37799 12086.89 12086.89 12086.89 12086.89 25953.26 25953.26 21627.72 21627.72 O 12086.89 12086.89 bcbs epo "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 8915.14 8915.14 bcbs hmo "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 8915.14 8915.14 bcbs hmo "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 8915.14 8915.14 bcbs pos "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 8915.14 8915.14 bcbs ppo "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 8915.14 8915.14 bcbs epo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 1401.36 1401.36 bcbs hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 1401.36 1401.36 bcbs hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 1401.36 1401.36 bcbs pos normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 1401.36 1401.36 bcbs ppo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 1401.36 1401.36 bcbs epo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 4051.53 4051.53 bcbs hmo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 4051.53 4051.53 bcbs hmo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 4051.53 4051.53 bcbs pos drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 4051.53 4051.53 bcbs ppo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 4051.53 4051.53 bcbs epo "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 4483.23 4483.23 bcbs hmo "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 4483.23 4483.23 bcbs hmo "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 4483.23 4483.23 bcbs pos "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 4483.23 4483.23 bcbs ppo "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 4483.23 4483.23 bcbs epo zoledronic acid 1mg cpt J3489 487.33 487.33 162.77 162.77 1039.22 1039.22 866.02 866.02 O 487.33 487.33 bcbs hmo zoledronic acid 1mg cpt J3489 487.33 487.33 162.77 162.77 1039.22 1039.22 866.02 866.02 O 487.33 487.33 bcbs hmo zoledronic acid 1mg cpt J3489 487.33 487.33 162.77 162.77 1039.22 1039.22 866.02 866.02 O 487.33 487.33 bcbs pos zoledronic acid 1mg cpt J3489 487.33 487.33 162.77 162.77 1039.22 1039.22 866.02 866.02 O 487.33 487.33 bcbs ppo zoledronic acid 1mg cpt J3489 487.33 487.33 162.77 162.77 1039.22 1039.22 866.02 866.02 O 487.33 487.33 bcbs epo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 975.92 975.92 bcbs hmo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 975.92 975.92 bcbs hmo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 975.92 975.92 bcbs pos inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 975.92 975.92 bcbs ppo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 975.92 975.92 bcbs epo Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 8915.14 8915.14 bcbs hmo Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 8915.14 8915.14 bcbs hmo Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 8915.14 8915.14 bcbs pos Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 8915.14 8915.14 bcbs ppo Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 8915.14 8915.14 bcbs epo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 694.06 694.06 694.06 694.06 1418.72 1418.72 1182.27 1182.27 O 694.06 694.06 bcbs hmo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 694.06 694.06 694.06 694.06 1418.72 1418.72 1182.27 1182.27 O 694.06 694.06 bcbs hmo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 694.06 694.06 694.06 694.06 1418.72 1418.72 1182.27 1182.27 O 694.06 694.06 bcbs pos "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 694.06 694.06 694.06 694.06 1418.72 1418.72 1182.27 1182.27 O 694.06 694.06 bcbs ppo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 694.06 694.06 694.06 694.06 1418.72 1418.72 1182.27 1182.27 O 694.06 694.06 bcbs epo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 1362.97 1362.97 bcbs hmo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 1362.97 1362.97 bcbs hmo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 1362.97 1362.97 bcbs pos inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 1362.97 1362.97 bcbs ppo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 1362.97 1362.97 bcbs epo "Removal of soft tissue at roof of mouth, simple" cpt 42140 3378.8 3378.8 3378.8 3378.8 19919.93 19919.93 16599.94 16599.94 O 3378.8 3378.8 bcbs hmo "Removal of soft tissue at roof of mouth, simple" cpt 42140 3378.8 3378.8 3378.8 3378.8 19919.93 19919.93 16599.94 16599.94 O 3378.8 3378.8 bcbs hmo "Removal of soft tissue at roof of mouth, simple" cpt 42140 3378.8 3378.8 3378.8 3378.8 19919.93 19919.93 16599.94 16599.94 O 3378.8 3378.8 bcbs pos "Removal of soft tissue at roof of mouth, simple" cpt 42140 3378.8 3378.8 3378.8 3378.8 19919.93 19919.93 16599.94 16599.94 O 3378.8 3378.8 bcbs ppo "Removal of soft tissue at roof of mouth, simple" cpt 42140 3378.8 3378.8 3378.8 3378.8 19919.93 19919.93 16599.94 16599.94 O 3378.8 3378.8 bcbs epo Partial removal of salivary gland growth with release of facial nerve cpt 42415 10684.99 10684.99 10684.99 10684.99 41713.18 41713.18 34760.98 34760.98 O 10684.99 10684.99 bcbs hmo Partial removal of salivary gland growth with release of facial nerve cpt 42415 10684.99 10684.99 10684.99 10684.99 41713.18 41713.18 34760.98 34760.98 O 10684.99 10684.99 bcbs hmo Partial removal of salivary gland growth with release of facial nerve cpt 42415 10684.99 10684.99 10684.99 10684.99 41713.18 41713.18 34760.98 34760.98 O 10684.99 10684.99 bcbs pos Partial removal of salivary gland growth with release of facial nerve cpt 42415 10684.99 10684.99 10684.99 10684.99 41713.18 41713.18 34760.98 34760.98 O 10684.99 10684.99 bcbs ppo Partial removal of salivary gland growth with release of facial nerve cpt 42415 10684.99 10684.99 10684.99 10684.99 41713.18 41713.18 34760.98 34760.98 O 10684.99 10684.99 bcbs epo vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 15987.99 15987.99 bcbs hmo vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 15987.99 15987.99 bcbs hmo vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 15987.99 15987.99 bcbs pos vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 15987.99 15987.99 bcbs ppo vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 15987.99 15987.99 bcbs epo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2213.69 2213.69 bcbs hmo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2213.69 2213.69 bcbs hmo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2213.69 2213.69 bcbs pos Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2213.69 2213.69 bcbs ppo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 2213.69 2213.69 bcbs epo hydroxyzine hcl injection cpt J3410 1086.21 1086.21 1086.21 1086.21 2616.41 2616.41 2180.34 2180.34 O 1086.21 1086.21 bcbs hmo hydroxyzine hcl injection cpt J3410 1086.21 1086.21 1086.21 1086.21 2616.41 2616.41 2180.34 2180.34 O 1086.21 1086.21 bcbs hmo hydroxyzine hcl injection cpt J3410 1086.21 1086.21 1086.21 1086.21 2616.41 2616.41 2180.34 2180.34 O 1086.21 1086.21 bcbs pos hydroxyzine hcl injection cpt J3410 1086.21 1086.21 1086.21 1086.21 2616.41 2616.41 2180.34 2180.34 O 1086.21 1086.21 bcbs ppo hydroxyzine hcl injection cpt J3410 1086.21 1086.21 1086.21 1086.21 2616.41 2616.41 2180.34 2180.34 O 1086.21 1086.21 bcbs epo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 4236.59 4236.59 bcbs hmo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 4236.59 4236.59 bcbs hmo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 4236.59 4236.59 bcbs pos "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 4236.59 4236.59 bcbs ppo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 4236.59 4236.59 bcbs epo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 3794.74 3794.74 bcbs hmo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 3794.74 3794.74 bcbs hmo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 3794.74 3794.74 bcbs pos vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 3794.74 3794.74 bcbs ppo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 3794.74 3794.74 bcbs epo triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 4701.08 4701.08 bcbs hmo triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 4701.08 4701.08 bcbs hmo triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 4701.08 4701.08 bcbs pos triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 4701.08 4701.08 bcbs ppo triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 4701.08 4701.08 bcbs epo chlorpromazine hcl injection cpt J3230 2332.93 2332.93 535.33 535.33 3739.15 3739.15 3115.96 3115.96 O 535.33 535.33 bcbs hmo chlorpromazine hcl injection cpt J3230 2332.93 2332.93 535.33 535.33 3739.15 3739.15 3115.96 3115.96 O 535.33 535.33 bcbs hmo chlorpromazine hcl injection cpt J3230 2332.93 2332.93 535.33 535.33 3739.15 3739.15 3115.96 3115.96 O 535.33 535.33 bcbs pos chlorpromazine hcl injection cpt J3230 2332.93 2332.93 535.33 535.33 3739.15 3739.15 3115.96 3115.96 O 535.33 535.33 bcbs ppo chlorpromazine hcl injection cpt J3230 2332.93 2332.93 535.33 535.33 3739.15 3739.15 3115.96 3115.96 O 535.33 535.33 bcbs epo terbutaline sulfate inj cpt J3105 603.59 603.59 197.68 197.68 3304.33 3304.33 2753.61 2753.61 O 603.59 603.59 bcbs hmo terbutaline sulfate inj cpt J3105 603.59 603.59 197.68 197.68 3304.33 3304.33 2753.61 2753.61 O 603.59 603.59 bcbs hmo terbutaline sulfate inj cpt J3105 603.59 603.59 197.68 197.68 3304.33 3304.33 2753.61 2753.61 O 603.59 603.59 bcbs pos terbutaline sulfate inj cpt J3105 603.59 603.59 197.68 197.68 3304.33 3304.33 2753.61 2753.61 O 603.59 603.59 bcbs ppo terbutaline sulfate inj cpt J3105 603.59 603.59 197.68 197.68 3304.33 3304.33 2753.61 2753.61 O 603.59 603.59 bcbs epo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 6177.54 6177.54 bcbs hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 6177.54 6177.54 bcbs hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 6177.54 6177.54 bcbs pos fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 6177.54 6177.54 bcbs ppo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 6177.54 6177.54 bcbs epo Diagnostic examination of large bowel using an endoscope inserted through surgically created opening into large bowel from body wall (colostomy) cpt 44388 1116.17 1116.17 676.71 676.71 3362.39 3362.39 2801.99 2801.99 O 1116.17 1116.17 bcbs hmo Diagnostic examination of large bowel using an endoscope inserted through surgically created opening into large bowel from body wall (colostomy) cpt 44388 1116.17 1116.17 676.71 676.71 3362.39 3362.39 2801.99 2801.99 O 1116.17 1116.17 bcbs hmo Diagnostic examination of large bowel using an endoscope inserted through surgically created opening into large bowel from body wall (colostomy) cpt 44388 1116.17 1116.17 676.71 676.71 3362.39 3362.39 2801.99 2801.99 O 1116.17 1116.17 bcbs pos Diagnostic examination of large bowel using an endoscope inserted through surgically created opening into large bowel from body wall (colostomy) cpt 44388 1116.17 1116.17 676.71 676.71 3362.39 3362.39 2801.99 2801.99 O 1116.17 1116.17 bcbs ppo Diagnostic examination of large bowel using an endoscope inserted through surgically created opening into large bowel from body wall (colostomy) cpt 44388 1116.17 1116.17 676.71 676.71 3362.39 3362.39 2801.99 2801.99 O 1116.17 1116.17 bcbs epo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 2009.92 2009.92 bcbs hmo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 2009.92 2009.92 bcbs hmo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 2009.92 2009.92 bcbs pos alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 2009.92 2009.92 bcbs ppo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 2009.92 2009.92 bcbs epo Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 2049.34 2049.34 bcbs hmo Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 2049.34 2049.34 bcbs hmo Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 2049.34 2049.34 bcbs pos Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 2049.34 2049.34 bcbs ppo Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 2049.34 2049.34 bcbs epo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 786.4 786.4 bcbs hmo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 786.4 786.4 bcbs hmo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 786.4 786.4 bcbs pos methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 786.4 786.4 bcbs ppo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 786.4 786.4 bcbs epo ropivacaine hcl injection cpt J2795 7567.25 7567.25 4940.62 4940.62 35964.18 35964.18 29970.15 29970.15 O 7567.25 7567.25 bcbs hmo ropivacaine hcl injection cpt J2795 7567.25 7567.25 4940.62 4940.62 35964.18 35964.18 29970.15 29970.15 O 7567.25 7567.25 bcbs hmo ropivacaine hcl injection cpt J2795 7567.25 7567.25 4940.62 4940.62 35964.18 35964.18 29970.15 29970.15 O 7567.25 7567.25 bcbs pos ropivacaine hcl injection cpt J2795 7567.25 7567.25 4940.62 4940.62 35964.18 35964.18 29970.15 29970.15 O 7567.25 7567.25 bcbs ppo ropivacaine hcl injection cpt J2795 7567.25 7567.25 4940.62 4940.62 35964.18 35964.18 29970.15 29970.15 O 7567.25 7567.25 bcbs epo rho d immune globulin inj cpt J2790 1331.33 1331.33 291.97 291.97 3727.37 3727.37 3106.14 3106.14 O 1331.33 1331.33 bcbs hmo rho d immune globulin inj cpt J2790 1331.33 1331.33 291.97 291.97 3727.37 3727.37 3106.14 3106.14 O 1331.33 1331.33 bcbs hmo rho d immune globulin inj cpt J2790 1331.33 1331.33 291.97 291.97 3727.37 3727.37 3106.14 3106.14 O 1331.33 1331.33 bcbs pos rho d immune globulin inj cpt J2790 1331.33 1331.33 291.97 291.97 3727.37 3727.37 3106.14 3106.14 O 1331.33 1331.33 bcbs ppo rho d immune globulin inj cpt J2790 1331.33 1331.33 291.97 291.97 3727.37 3727.37 3106.14 3106.14 O 1331.33 1331.33 bcbs epo "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1913.87 1913.87 bcbs hmo "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1913.87 1913.87 bcbs hmo "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1913.87 1913.87 bcbs pos "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1913.87 1913.87 bcbs ppo "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1913.87 1913.87 bcbs epo "Removal of tissue abnormalities, tumors, or polyps of large bowel by hot biopsy forceps, using a flexible endoscope" cpt 45384 1768 1768 848.56 848.56 5615.62 5615.62 4679.68 4679.68 O 1768 1768 bcbs hmo "Removal of tissue abnormalities, tumors, or polyps of large bowel by hot biopsy forceps, using a flexible endoscope" cpt 45384 1768 1768 848.56 848.56 5615.62 5615.62 4679.68 4679.68 O 1768 1768 bcbs hmo "Removal of tissue abnormalities, tumors, or polyps of large bowel by hot biopsy forceps, using a flexible endoscope" cpt 45384 1768 1768 848.56 848.56 5615.62 5615.62 4679.68 4679.68 O 1768 1768 bcbs pos "Removal of tissue abnormalities, tumors, or polyps of large bowel by hot biopsy forceps, using a flexible endoscope" cpt 45384 1768 1768 848.56 848.56 5615.62 5615.62 4679.68 4679.68 O 1768 1768 bcbs ppo "Removal of tissue abnormalities, tumors, or polyps of large bowel by hot biopsy forceps, using a flexible endoscope" cpt 45384 1768 1768 848.56 848.56 5615.62 5615.62 4679.68 4679.68 O 1768 1768 bcbs epo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 2752.93 2752.93 bcbs hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 2752.93 2752.93 bcbs hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 2752.93 2752.93 bcbs pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 2752.93 2752.93 bcbs ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 2752.93 2752.93 bcbs epo ranitidine hydrochloride inj cpt J2780 5664.76 5664.76 834 834 14567.26 14567.26 12139.38 12139.38 O 834 834 bcbs hmo ranitidine hydrochloride inj cpt J2780 5664.76 5664.76 834 834 14567.26 14567.26 12139.38 12139.38 O 834 834 bcbs hmo ranitidine hydrochloride inj cpt J2780 5664.76 5664.76 834 834 14567.26 14567.26 12139.38 12139.38 O 834 834 bcbs pos ranitidine hydrochloride inj cpt J2780 5664.76 5664.76 834 834 14567.26 14567.26 12139.38 12139.38 O 834 834 bcbs ppo ranitidine hydrochloride inj cpt J2780 5664.76 5664.76 834 834 14567.26 14567.26 12139.38 12139.38 O 834 834 bcbs epo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 1611.6 1611.6 bcbs hmo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 1611.6 1611.6 bcbs hmo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 1611.6 1611.6 bcbs pos metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 1611.6 1611.6 bcbs ppo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 1611.6 1611.6 bcbs epo Removal of multiple external benign growths (papillas or tags) of anus cpt 46230 3621.48 3621.48 3621.48 3621.48 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs hmo Removal of multiple external benign growths (papillas or tags) of anus cpt 46230 3621.48 3621.48 3621.48 3621.48 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs hmo Removal of multiple external benign growths (papillas or tags) of anus cpt 46230 3621.48 3621.48 3621.48 3621.48 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs pos Removal of multiple external benign growths (papillas or tags) of anus cpt 46230 3621.48 3621.48 3621.48 3621.48 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs ppo Removal of multiple external benign growths (papillas or tags) of anus cpt 46230 3621.48 3621.48 3621.48 3621.48 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs epo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 7599.47 7599.47 bcbs hmo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 7599.47 7599.47 bcbs hmo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 7599.47 7599.47 bcbs pos neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 7599.47 7599.47 bcbs ppo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 7599.47 7599.47 bcbs epo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 3333.89 3333.89 bcbs hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 3333.89 3333.89 bcbs hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 3333.89 3333.89 bcbs pos "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 3333.89 3333.89 bcbs ppo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 3333.89 3333.89 bcbs epo piperacillin/tazobactam cpt J2543 4282.09 4282.09 389.58 389.58 13027.27 13027.27 10856.06 10856.06 O 3569.24 3569.24 bcbs hmo piperacillin/tazobactam cpt J2543 4282.09 4282.09 389.58 389.58 13027.27 13027.27 10856.06 10856.06 O 3569.24 3569.24 bcbs hmo piperacillin/tazobactam cpt J2543 4282.09 4282.09 389.58 389.58 13027.27 13027.27 10856.06 10856.06 O 3569.24 3569.24 bcbs pos piperacillin/tazobactam cpt J2543 4282.09 4282.09 389.58 389.58 13027.27 13027.27 10856.06 10856.06 O 3569.24 3569.24 bcbs ppo piperacillin/tazobactam cpt J2543 4282.09 4282.09 389.58 389.58 13027.27 13027.27 10856.06 10856.06 O 3569.24 3569.24 bcbs epo "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 21516.54 21516.54 bcbs hmo "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 21516.54 21516.54 bcbs hmo "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 21516.54 21516.54 bcbs pos "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 21516.54 21516.54 bcbs ppo "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 21516.54 21516.54 bcbs epo "Benzodiazepines levels, 1-12" cpt 80346 2.35 2.35 2.35 2.35 100.16 100.16 83.47 83.47 O 2.35 2.35 bcbs hmo "Benzodiazepines levels, 1-12" cpt 80346 2.35 2.35 2.35 2.35 100.16 100.16 83.47 83.47 O 2.35 2.35 bcbs hmo "Benzodiazepines levels, 1-12" cpt 80346 2.35 2.35 2.35 2.35 100.16 100.16 83.47 83.47 O 2.35 2.35 bcbs pos "Benzodiazepines levels, 1-12" cpt 80346 2.35 2.35 2.35 2.35 100.16 100.16 83.47 83.47 O 2.35 2.35 bcbs ppo "Benzodiazepines levels, 1-12" cpt 80346 2.35 2.35 2.35 2.35 100.16 100.16 83.47 83.47 O 2.35 2.35 bcbs epo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 2537.15 2537.15 bcbs hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 2537.15 2537.15 bcbs hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 2537.15 2537.15 bcbs pos palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 2537.15 2537.15 bcbs ppo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 2537.15 2537.15 bcbs epo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 3554.71 3554.71 bcbs hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 3554.71 3554.71 bcbs hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 3554.71 3554.71 bcbs pos ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 3554.71 3554.71 bcbs ppo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 3554.71 3554.71 bcbs epo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 8443.07 8443.07 bcbs hmo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 8443.07 8443.07 bcbs hmo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 8443.07 8443.07 bcbs pos Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 8443.07 8443.07 bcbs ppo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 8443.07 8443.07 bcbs epo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 6466.87 6466.87 bcbs hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 6466.87 6466.87 bcbs hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 6466.87 6466.87 bcbs pos phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 6466.87 6466.87 bcbs ppo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 6466.87 6466.87 bcbs epo orphenadrine injection cpt J2360 690.8 690.8 690.8 690.8 1357.74 1357.74 1131.45 1131.45 O 690.8 690.8 bcbs hmo orphenadrine injection cpt J2360 690.8 690.8 690.8 690.8 1357.74 1357.74 1131.45 1131.45 O 690.8 690.8 bcbs hmo orphenadrine injection cpt J2360 690.8 690.8 690.8 690.8 1357.74 1357.74 1131.45 1131.45 O 690.8 690.8 bcbs pos orphenadrine injection cpt J2360 690.8 690.8 690.8 690.8 1357.74 1357.74 1131.45 1131.45 O 690.8 690.8 bcbs ppo orphenadrine injection cpt J2360 690.8 690.8 690.8 690.8 1357.74 1357.74 1131.45 1131.45 O 690.8 690.8 bcbs epo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1116.89 1116.89 bcbs hmo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1116.89 1116.89 bcbs hmo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1116.89 1116.89 bcbs pos Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1116.89 1116.89 bcbs ppo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1116.89 1116.89 bcbs epo omalizumab injection cpt J2357 1683.11 1683.11 879.24 879.24 6128.9 6128.9 5107.42 5107.42 O 879.24 879.24 bcbs hmo omalizumab injection cpt J2357 1683.11 1683.11 879.24 879.24 6128.9 6128.9 5107.42 5107.42 O 879.24 879.24 bcbs hmo omalizumab injection cpt J2357 1683.11 1683.11 879.24 879.24 6128.9 6128.9 5107.42 5107.42 O 879.24 879.24 bcbs pos omalizumab injection cpt J2357 1683.11 1683.11 879.24 879.24 6128.9 6128.9 5107.42 5107.42 O 879.24 879.24 bcbs ppo omalizumab injection cpt J2357 1683.11 1683.11 879.24 879.24 6128.9 6128.9 5107.42 5107.42 O 879.24 879.24 bcbs epo "octreotide injection, depot" cpt J2353 3083.65 3083.65 2805.19 2805.19 15357.98 15357.98 12798.32 12798.32 O 2805.19 2805.19 bcbs hmo "octreotide injection, depot" cpt J2353 3083.65 3083.65 2805.19 2805.19 15357.98 15357.98 12798.32 12798.32 O 2805.19 2805.19 bcbs hmo "octreotide injection, depot" cpt J2353 3083.65 3083.65 2805.19 2805.19 15357.98 15357.98 12798.32 12798.32 O 2805.19 2805.19 bcbs pos "octreotide injection, depot" cpt J2353 3083.65 3083.65 2805.19 2805.19 15357.98 15357.98 12798.32 12798.32 O 2805.19 2805.19 bcbs ppo "octreotide injection, depot" cpt J2353 3083.65 3083.65 2805.19 2805.19 15357.98 15357.98 12798.32 12798.32 O 2805.19 2805.19 bcbs epo "injection, ocrelizumab, 1 mg" cpt J2350 759.3 759.3 759.3 759.3 52446.04 52446.04 43705.03 43705.03 O 759.3 759.3 bcbs hmo "injection, ocrelizumab, 1 mg" cpt J2350 759.3 759.3 759.3 759.3 52446.04 52446.04 43705.03 43705.03 O 759.3 759.3 bcbs hmo "injection, ocrelizumab, 1 mg" cpt J2350 759.3 759.3 759.3 759.3 52446.04 52446.04 43705.03 43705.03 O 759.3 759.3 bcbs pos "injection, ocrelizumab, 1 mg" cpt J2350 759.3 759.3 759.3 759.3 52446.04 52446.04 43705.03 43705.03 O 759.3 759.3 bcbs ppo "injection, ocrelizumab, 1 mg" cpt J2350 759.3 759.3 759.3 759.3 52446.04 52446.04 43705.03 43705.03 O 759.3 759.3 bcbs epo Biopsy of abdomen using an endoscope cpt 49321 7453.01 7453.01 4282.09 4282.09 31398.76 31398.76 26165.63 26165.63 O 6997.25 6997.25 bcbs hmo Biopsy of abdomen using an endoscope cpt 49321 7453.01 7453.01 4282.09 4282.09 31398.76 31398.76 26165.63 26165.63 O 6997.25 6997.25 bcbs hmo Biopsy of abdomen using an endoscope cpt 49321 7453.01 7453.01 4282.09 4282.09 31398.76 31398.76 26165.63 26165.63 O 6997.25 6997.25 bcbs pos Biopsy of abdomen using an endoscope cpt 49321 7453.01 7453.01 4282.09 4282.09 31398.76 31398.76 26165.63 26165.63 O 6997.25 6997.25 bcbs ppo Biopsy of abdomen using an endoscope cpt 49321 7453.01 7453.01 4282.09 4282.09 31398.76 31398.76 26165.63 26165.63 O 6997.25 6997.25 bcbs epo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 1781.57 1781.57 bcbs hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 1781.57 1781.57 bcbs hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 1781.57 1781.57 bcbs pos morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 1781.57 1781.57 bcbs ppo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 1781.57 1781.57 bcbs epo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 5122.02 5122.02 bcbs hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 5122.02 5122.02 bcbs hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 5122.02 5122.02 bcbs pos inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 5122.02 5122.02 bcbs ppo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 5122.02 5122.02 bcbs epo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 4701.08 4701.08 bcbs hmo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 4701.08 4701.08 bcbs hmo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 4701.08 4701.08 bcbs pos meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 4701.08 4701.08 bcbs ppo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 4701.08 4701.08 bcbs epo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 7562.13 7562.13 bcbs hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 7562.13 7562.13 bcbs hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 7562.13 7562.13 bcbs pos Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 7562.13 7562.13 bcbs ppo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 7562.13 7562.13 bcbs epo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 1971.28 1971.28 bcbs hmo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 1971.28 1971.28 bcbs hmo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 1971.28 1971.28 bcbs pos mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 1971.28 1971.28 bcbs ppo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 1971.28 1971.28 bcbs epo Repositioning of recurrent groin hernia using an endoscope cpt 49651 7519.16 7519.16 3946.37 3946.37 32495.42 32495.42 27079.52 27079.52 O 7519.16 7519.16 bcbs hmo Repositioning of recurrent groin hernia using an endoscope cpt 49651 7519.16 7519.16 3946.37 3946.37 32495.42 32495.42 27079.52 27079.52 O 7519.16 7519.16 bcbs hmo Repositioning of recurrent groin hernia using an endoscope cpt 49651 7519.16 7519.16 3946.37 3946.37 32495.42 32495.42 27079.52 27079.52 O 7519.16 7519.16 bcbs pos Repositioning of recurrent groin hernia using an endoscope cpt 49651 7519.16 7519.16 3946.37 3946.37 32495.42 32495.42 27079.52 27079.52 O 7519.16 7519.16 bcbs ppo Repositioning of recurrent groin hernia using an endoscope cpt 49651 7519.16 7519.16 3946.37 3946.37 32495.42 32495.42 27079.52 27079.52 O 7519.16 7519.16 bcbs epo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 1486.86 1486.86 bcbs hmo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 1486.86 1486.86 bcbs hmo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 1486.86 1486.86 bcbs pos lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 1486.86 1486.86 bcbs ppo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 1486.86 1486.86 bcbs epo Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 7918.7 7918.7 bcbs hmo Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 7918.7 7918.7 bcbs hmo Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 7918.7 7918.7 bcbs pos Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 7918.7 7918.7 bcbs ppo Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 7918.7 7918.7 bcbs epo "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7600.98 7600.98 bcbs hmo "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7600.98 7600.98 bcbs hmo "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7600.98 7600.98 bcbs pos "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7600.98 7600.98 bcbs ppo "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7600.98 7600.98 bcbs epo lidocaine injection cpt J2001 2164.03 2164.03 686.47 686.47 17322.78 17322.78 14435.65 14435.65 O 1510.68 1510.68 bcbs hmo lidocaine injection cpt J2001 2164.03 2164.03 686.47 686.47 17322.78 17322.78 14435.65 14435.65 O 1510.68 1510.68 bcbs hmo lidocaine injection cpt J2001 2164.03 2164.03 686.47 686.47 17322.78 17322.78 14435.65 14435.65 O 1510.68 1510.68 bcbs pos lidocaine injection cpt J2001 2164.03 2164.03 686.47 686.47 17322.78 17322.78 14435.65 14435.65 O 1510.68 1510.68 bcbs ppo lidocaine injection cpt J2001 2164.03 2164.03 686.47 686.47 17322.78 17322.78 14435.65 14435.65 O 1510.68 1510.68 bcbs epo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 1160.73 1160.73 bcbs hmo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 1160.73 1160.73 bcbs hmo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 1160.73 1160.73 bcbs pos "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 1160.73 1160.73 bcbs ppo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 1160.73 1160.73 bcbs epo levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 4436.99 4436.99 bcbs hmo levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 4436.99 4436.99 bcbs hmo levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 4436.99 4436.99 bcbs pos levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 4436.99 4436.99 bcbs ppo levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 4436.99 4436.99 bcbs epo Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 11999.48 11999.48 bcbs hmo Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 11999.48 11999.48 bcbs hmo Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 11999.48 11999.48 bcbs pos Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 11999.48 11999.48 bcbs ppo Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 11999.48 11999.48 bcbs epo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1599.57 1599.57 bcbs hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1599.57 1599.57 bcbs hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1599.57 1599.57 bcbs pos furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1599.57 1599.57 bcbs ppo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1599.57 1599.57 bcbs epo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 1409.32 1409.32 bcbs hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 1409.32 1409.32 bcbs hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 1409.32 1409.32 bcbs pos ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 1409.32 1409.32 bcbs ppo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 1409.32 1409.32 bcbs epo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 2904.35 2904.35 bcbs hmo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 2904.35 2904.35 bcbs hmo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 2904.35 2904.35 bcbs pos inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 2904.35 2904.35 bcbs ppo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 2904.35 2904.35 bcbs epo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 7503.88 7503.88 bcbs hmo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 7503.88 7503.88 bcbs hmo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 7503.88 7503.88 bcbs pos inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 7503.88 7503.88 bcbs ppo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 7503.88 7503.88 bcbs epo Dilation of the bladder using an endoscope under general or spinal anesthesia cpt 52260 4681.97 4681.97 4681.97 4681.97 13442.18 13442.18 11201.82 11201.82 O 4681.97 4681.97 bcbs hmo Dilation of the bladder using an endoscope under general or spinal anesthesia cpt 52260 4681.97 4681.97 4681.97 4681.97 13442.18 13442.18 11201.82 11201.82 O 4681.97 4681.97 bcbs hmo Dilation of the bladder using an endoscope under general or spinal anesthesia cpt 52260 4681.97 4681.97 4681.97 4681.97 13442.18 13442.18 11201.82 11201.82 O 4681.97 4681.97 bcbs pos Dilation of the bladder using an endoscope under general or spinal anesthesia cpt 52260 4681.97 4681.97 4681.97 4681.97 13442.18 13442.18 11201.82 11201.82 O 4681.97 4681.97 bcbs ppo Dilation of the bladder using an endoscope under general or spinal anesthesia cpt 52260 4681.97 4681.97 4681.97 4681.97 13442.18 13442.18 11201.82 11201.82 O 4681.97 4681.97 bcbs epo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs pos inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 132.26 132.26 bcbs epo haloperidol injection cpt J1630 943.3 943.3 215.49 215.49 4416.9 4416.9 3680.75 3680.75 O 215.49 215.49 bcbs hmo haloperidol injection cpt J1630 943.3 943.3 215.49 215.49 4416.9 4416.9 3680.75 3680.75 O 215.49 215.49 bcbs hmo haloperidol injection cpt J1630 943.3 943.3 215.49 215.49 4416.9 4416.9 3680.75 3680.75 O 215.49 215.49 bcbs pos haloperidol injection cpt J1630 943.3 943.3 215.49 215.49 4416.9 4416.9 3680.75 3680.75 O 215.49 215.49 bcbs ppo haloperidol injection cpt J1630 943.3 943.3 215.49 215.49 4416.9 4416.9 3680.75 3680.75 O 215.49 215.49 bcbs epo glucagon hydrochloride/1 mg cpt J1610 496.24 496.24 496.24 496.24 3696.37 3696.37 3080.31 3080.31 O 496.24 496.24 bcbs hmo glucagon hydrochloride/1 mg cpt J1610 496.24 496.24 496.24 496.24 3696.37 3696.37 3080.31 3080.31 O 496.24 496.24 bcbs hmo glucagon hydrochloride/1 mg cpt J1610 496.24 496.24 496.24 496.24 3696.37 3696.37 3080.31 3080.31 O 496.24 496.24 bcbs pos glucagon hydrochloride/1 mg cpt J1610 496.24 496.24 496.24 496.24 3696.37 3696.37 3080.31 3080.31 O 496.24 496.24 bcbs ppo glucagon hydrochloride/1 mg cpt J1610 496.24 496.24 496.24 496.24 3696.37 3696.37 3080.31 3080.31 O 496.24 496.24 bcbs epo Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 4436.99 4436.99 bcbs hmo Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 4436.99 4436.99 bcbs hmo Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 4436.99 4436.99 bcbs pos Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 4436.99 4436.99 bcbs ppo Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 4436.99 4436.99 bcbs epo garamycin gentamicin inj cpt J1580 10542.6 10542.6 2021.39 2021.39 29695.73 29695.73 24746.44 24746.44 O 10499.65 10499.65 bcbs hmo garamycin gentamicin inj cpt J1580 10542.6 10542.6 2021.39 2021.39 29695.73 29695.73 24746.44 24746.44 O 10499.65 10499.65 bcbs hmo garamycin gentamicin inj cpt J1580 10542.6 10542.6 2021.39 2021.39 29695.73 29695.73 24746.44 24746.44 O 10499.65 10499.65 bcbs pos garamycin gentamicin inj cpt J1580 10542.6 10542.6 2021.39 2021.39 29695.73 29695.73 24746.44 24746.44 O 10499.65 10499.65 bcbs ppo garamycin gentamicin inj cpt J1580 10542.6 10542.6 2021.39 2021.39 29695.73 29695.73 24746.44 24746.44 O 10499.65 10499.65 bcbs epo "inj fosnetupitant, palonoset" cpt J1454 15309.39 15309.39 1039.51 1039.51 3498.12 3498.12 2915.1 2915.1 O 1039.51 1039.51 bcbs hmo "inj fosnetupitant, palonoset" cpt J1454 15309.39 15309.39 1039.51 1039.51 3498.12 3498.12 2915.1 2915.1 O 1039.51 1039.51 bcbs hmo "inj fosnetupitant, palonoset" cpt J1454 15309.39 15309.39 1039.51 1039.51 3498.12 3498.12 2915.1 2915.1 O 1039.51 1039.51 bcbs pos "inj fosnetupitant, palonoset" cpt J1454 15309.39 15309.39 1039.51 1039.51 3498.12 3498.12 2915.1 2915.1 O 1039.51 1039.51 bcbs ppo "inj fosnetupitant, palonoset" cpt J1454 15309.39 15309.39 1039.51 1039.51 3498.12 3498.12 2915.1 2915.1 O 1039.51 1039.51 bcbs epo Removal or manipulation of stone in urinary duct (ureter) or kidney using an endoscope cpt 52352 4436.99 4436.99 2519.87 2519.87 23377.46 23377.46 19481.22 19481.22 O 4436.99 4436.99 bcbs hmo Removal or manipulation of stone in urinary duct (ureter) or kidney using an endoscope cpt 52352 4436.99 4436.99 2519.87 2519.87 23377.46 23377.46 19481.22 19481.22 O 4436.99 4436.99 bcbs hmo Removal or manipulation of stone in urinary duct (ureter) or kidney using an endoscope cpt 52352 4436.99 4436.99 2519.87 2519.87 23377.46 23377.46 19481.22 19481.22 O 4436.99 4436.99 bcbs pos Removal or manipulation of stone in urinary duct (ureter) or kidney using an endoscope cpt 52352 4436.99 4436.99 2519.87 2519.87 23377.46 23377.46 19481.22 19481.22 O 4436.99 4436.99 bcbs ppo Removal or manipulation of stone in urinary duct (ureter) or kidney using an endoscope cpt 52352 4436.99 4436.99 2519.87 2519.87 23377.46 23377.46 19481.22 19481.22 O 4436.99 4436.99 bcbs epo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 272.76 272.76 bcbs hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 272.76 272.76 bcbs hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 272.76 272.76 bcbs pos Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 272.76 272.76 bcbs ppo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 272.76 272.76 bcbs epo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 8848.19 8848.19 bcbs hmo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 8848.19 8848.19 bcbs hmo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 8848.19 8848.19 bcbs pos Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 8848.19 8848.19 bcbs ppo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 8848.19 8848.19 bcbs epo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 2286.87 2286.87 bcbs hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 2286.87 2286.87 bcbs hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 2286.87 2286.87 bcbs pos fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 2286.87 2286.87 bcbs ppo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 2286.87 2286.87 bcbs epo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 1152.77 1152.77 bcbs hmo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 1152.77 1152.77 bcbs hmo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 1152.77 1152.77 bcbs pos inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 1152.77 1152.77 bcbs ppo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 1152.77 1152.77 bcbs epo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 1077.64 1077.64 bcbs hmo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 1077.64 1077.64 bcbs hmo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 1077.64 1077.64 bcbs pos inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 1077.64 1077.64 bcbs ppo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 1077.64 1077.64 bcbs epo ertapenem injection cpt J1335 2076.66 2076.66 148.68 148.68 1092.52 1092.52 910.43 910.43 O 561.42 561.42 bcbs hmo ertapenem injection cpt J1335 2076.66 2076.66 148.68 148.68 1092.52 1092.52 910.43 910.43 O 561.42 561.42 bcbs hmo ertapenem injection cpt J1335 2076.66 2076.66 148.68 148.68 1092.52 1092.52 910.43 910.43 O 561.42 561.42 bcbs pos ertapenem injection cpt J1335 2076.66 2076.66 148.68 148.68 1092.52 1092.52 910.43 910.43 O 561.42 561.42 bcbs ppo ertapenem injection cpt J1335 2076.66 2076.66 148.68 148.68 1092.52 1092.52 910.43 910.43 O 561.42 561.42 bcbs epo eculizumab injection cpt J1300 12812.83 12812.83 12812.83 12812.83 94062.3 94062.3 78385.25 78385.25 O 12812.83 12812.83 bcbs hmo eculizumab injection cpt J1300 12812.83 12812.83 12812.83 12812.83 94062.3 94062.3 78385.25 78385.25 O 12812.83 12812.83 bcbs hmo eculizumab injection cpt J1300 12812.83 12812.83 12812.83 12812.83 94062.3 94062.3 78385.25 78385.25 O 12812.83 12812.83 bcbs pos eculizumab injection cpt J1300 12812.83 12812.83 12812.83 12812.83 94062.3 94062.3 78385.25 78385.25 O 12812.83 12812.83 bcbs ppo eculizumab injection cpt J1300 12812.83 12812.83 12812.83 12812.83 94062.3 94062.3 78385.25 78385.25 O 12812.83 12812.83 bcbs epo Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 1044.94 1044.94 bcbs hmo Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 1044.94 1044.94 bcbs hmo Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 1044.94 1044.94 bcbs pos Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 1044.94 1044.94 bcbs ppo Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 1044.94 1044.94 bcbs epo Removal of fluid accumulation in one testicle and sperm reservoir cpt 55040 5192.86 5192.86 2710.43 2710.43 18536.92 18536.92 15447.43 15447.43 O 5192.86 5192.86 bcbs hmo Removal of fluid accumulation in one testicle and sperm reservoir cpt 55040 5192.86 5192.86 2710.43 2710.43 18536.92 18536.92 15447.43 15447.43 O 5192.86 5192.86 bcbs hmo Removal of fluid accumulation in one testicle and sperm reservoir cpt 55040 5192.86 5192.86 2710.43 2710.43 18536.92 18536.92 15447.43 15447.43 O 5192.86 5192.86 bcbs pos Removal of fluid accumulation in one testicle and sperm reservoir cpt 55040 5192.86 5192.86 2710.43 2710.43 18536.92 18536.92 15447.43 15447.43 O 5192.86 5192.86 bcbs ppo Removal of fluid accumulation in one testicle and sperm reservoir cpt 55040 5192.86 5192.86 2710.43 2710.43 18536.92 18536.92 15447.43 15447.43 O 5192.86 5192.86 bcbs epo Incision and drainage of abscess in scrotal sac of testicle cpt 55100 686.2 686.2 686.2 686.2 1178.7 1178.7 982.25 982.25 O 686.2 686.2 bcbs hmo Incision and drainage of abscess in scrotal sac of testicle cpt 55100 686.2 686.2 686.2 686.2 1178.7 1178.7 982.25 982.25 O 686.2 686.2 bcbs hmo Incision and drainage of abscess in scrotal sac of testicle cpt 55100 686.2 686.2 686.2 686.2 1178.7 1178.7 982.25 982.25 O 686.2 686.2 bcbs pos Incision and drainage of abscess in scrotal sac of testicle cpt 55100 686.2 686.2 686.2 686.2 1178.7 1178.7 982.25 982.25 O 686.2 686.2 bcbs ppo Incision and drainage of abscess in scrotal sac of testicle cpt 55100 686.2 686.2 686.2 686.2 1178.7 1178.7 982.25 982.25 O 686.2 686.2 bcbs epo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1366.77 1366.77 bcbs hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1366.77 1366.77 bcbs hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1366.77 1366.77 bcbs pos diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1366.77 1366.77 bcbs ppo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1366.77 1366.77 bcbs epo Spermatic cord procedure using an endoscope cpt 55559 7519.16 7519.16 4282.09 4282.09 32160.6 32160.6 26800.5 26800.5 O 7519.16 7519.16 bcbs hmo Spermatic cord procedure using an endoscope cpt 55559 7519.16 7519.16 4282.09 4282.09 32160.6 32160.6 26800.5 26800.5 O 7519.16 7519.16 bcbs hmo Spermatic cord procedure using an endoscope cpt 55559 7519.16 7519.16 4282.09 4282.09 32160.6 32160.6 26800.5 26800.5 O 7519.16 7519.16 bcbs pos Spermatic cord procedure using an endoscope cpt 55559 7519.16 7519.16 4282.09 4282.09 32160.6 32160.6 26800.5 26800.5 O 7519.16 7519.16 bcbs ppo Spermatic cord procedure using an endoscope cpt 55559 7519.16 7519.16 4282.09 4282.09 32160.6 32160.6 26800.5 26800.5 O 7519.16 7519.16 bcbs epo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7125.29 7125.29 bcbs hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7125.29 7125.29 bcbs hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7125.29 7125.29 bcbs pos hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7125.29 7125.29 bcbs ppo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 7125.29 7125.29 bcbs epo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4460.63 4460.63 bcbs hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4460.63 4460.63 bcbs hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4460.63 4460.63 bcbs pos dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4460.63 4460.63 bcbs ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4460.63 4460.63 bcbs epo Removal or destruction of cervix with electrical cautery cpt 57522 2364.21 2364.21 2218.48 2218.48 17203.74 17203.74 14336.45 14336.45 O 2364.21 2364.21 bcbs hmo Removal or destruction of cervix with electrical cautery cpt 57522 2364.21 2364.21 2218.48 2218.48 17203.74 17203.74 14336.45 14336.45 O 2364.21 2364.21 bcbs hmo Removal or destruction of cervix with electrical cautery cpt 57522 2364.21 2364.21 2218.48 2218.48 17203.74 17203.74 14336.45 14336.45 O 2364.21 2364.21 bcbs pos Removal or destruction of cervix with electrical cautery cpt 57522 2364.21 2364.21 2218.48 2218.48 17203.74 17203.74 14336.45 14336.45 O 2364.21 2364.21 bcbs ppo Removal or destruction of cervix with electrical cautery cpt 57522 2364.21 2364.21 2218.48 2218.48 17203.74 17203.74 14336.45 14336.45 O 2364.21 2364.21 bcbs epo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1180.35 1180.35 bcbs hmo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1180.35 1180.35 bcbs hmo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1180.35 1180.35 bcbs pos methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1180.35 1180.35 bcbs ppo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1180.35 1180.35 bcbs epo Biopsy and/or removal of polyp of the uterus using an endoscope cpt 58558 5405.17 5405.17 2093.55 2093.55 24489.84 24489.84 20408.2 20408.2 O 5405.17 5405.17 bcbs hmo Biopsy and/or removal of polyp of the uterus using an endoscope cpt 58558 5405.17 5405.17 2093.55 2093.55 24489.84 24489.84 20408.2 20408.2 O 5405.17 5405.17 bcbs hmo Biopsy and/or removal of polyp of the uterus using an endoscope cpt 58558 5405.17 5405.17 2093.55 2093.55 24489.84 24489.84 20408.2 20408.2 O 5405.17 5405.17 bcbs pos Biopsy and/or removal of polyp of the uterus using an endoscope cpt 58558 5405.17 5405.17 2093.55 2093.55 24489.84 24489.84 20408.2 20408.2 O 5405.17 5405.17 bcbs ppo Biopsy and/or removal of polyp of the uterus using an endoscope cpt 58558 5405.17 5405.17 2093.55 2093.55 24489.84 24489.84 20408.2 20408.2 O 5405.17 5405.17 bcbs epo Examination of uterus with destruction of uterine lining using an endoscope cpt 58563 6142.86 6142.86 4033.08 4033.08 27275.76 27275.76 22729.8 22729.8 O 6142.86 6142.86 bcbs hmo Examination of uterus with destruction of uterine lining using an endoscope cpt 58563 6142.86 6142.86 4033.08 4033.08 27275.76 27275.76 22729.8 22729.8 O 6142.86 6142.86 bcbs hmo Examination of uterus with destruction of uterine lining using an endoscope cpt 58563 6142.86 6142.86 4033.08 4033.08 27275.76 27275.76 22729.8 22729.8 O 6142.86 6142.86 bcbs pos Examination of uterus with destruction of uterine lining using an endoscope cpt 58563 6142.86 6142.86 4033.08 4033.08 27275.76 27275.76 22729.8 22729.8 O 6142.86 6142.86 bcbs ppo Examination of uterus with destruction of uterine lining using an endoscope cpt 58563 6142.86 6142.86 4033.08 4033.08 27275.76 27275.76 22729.8 22729.8 O 6142.86 6142.86 bcbs epo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1583.41 1583.41 bcbs hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1583.41 1583.41 bcbs hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1583.41 1583.41 bcbs pos denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1583.41 1583.41 bcbs ppo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1583.41 1583.41 bcbs epo Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 8548.35 8548.35 bcbs hmo Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 8548.35 8548.35 bcbs hmo Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 8548.35 8548.35 bcbs pos Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 8548.35 8548.35 bcbs ppo Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 8548.35 8548.35 bcbs epo daptomycin injection cpt J0878 269.44 269.44 214.57 214.57 1334.95 1334.95 1112.46 1112.46 O 240.65 240.65 bcbs hmo daptomycin injection cpt J0878 269.44 269.44 214.57 214.57 1334.95 1334.95 1112.46 1112.46 O 240.65 240.65 bcbs hmo daptomycin injection cpt J0878 269.44 269.44 214.57 214.57 1334.95 1334.95 1112.46 1112.46 O 240.65 240.65 bcbs pos daptomycin injection cpt J0878 269.44 269.44 214.57 214.57 1334.95 1334.95 1112.46 1112.46 O 240.65 240.65 bcbs ppo daptomycin injection cpt J0878 269.44 269.44 214.57 214.57 1334.95 1334.95 1112.46 1112.46 O 240.65 240.65 bcbs epo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1796.84 1796.84 bcbs hmo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1796.84 1796.84 bcbs hmo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1796.84 1796.84 bcbs pos prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1796.84 1796.84 bcbs ppo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1796.84 1796.84 bcbs epo Removal of ovaries and/or tubes using an endoscope cpt 58661 5642.61 5642.61 3975.41 3975.41 24783.68 24783.68 20653.07 20653.07 O 5642.61 5642.61 bcbs hmo Removal of ovaries and/or tubes using an endoscope cpt 58661 5642.61 5642.61 3975.41 3975.41 24783.68 24783.68 20653.07 20653.07 O 5642.61 5642.61 bcbs hmo Removal of ovaries and/or tubes using an endoscope cpt 58661 5642.61 5642.61 3975.41 3975.41 24783.68 24783.68 20653.07 20653.07 O 5642.61 5642.61 bcbs pos Removal of ovaries and/or tubes using an endoscope cpt 58661 5642.61 5642.61 3975.41 3975.41 24783.68 24783.68 20653.07 20653.07 O 5642.61 5642.61 bcbs ppo Removal of ovaries and/or tubes using an endoscope cpt 58661 5642.61 5642.61 3975.41 3975.41 24783.68 24783.68 20653.07 20653.07 O 5642.61 5642.61 bcbs epo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 5642.61 5642.61 bcbs hmo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 5642.61 5642.61 bcbs hmo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 5642.61 5642.61 bcbs pos Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 5642.61 5642.61 bcbs ppo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 5642.61 5642.61 bcbs epo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 3225.81 3225.81 bcbs hmo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 3225.81 3225.81 bcbs hmo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 3225.81 3225.81 bcbs pos ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 3225.81 3225.81 bcbs ppo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 3225.81 3225.81 bcbs epo Destruction of ovaries using an endoscope cpt 58670 8912.42 8912.42 3969.52 3969.52 20520.59 20520.59 17100.49 17100.49 O 8912.42 8912.42 bcbs hmo Destruction of ovaries using an endoscope cpt 58670 8912.42 8912.42 3969.52 3969.52 20520.59 20520.59 17100.49 17100.49 O 8912.42 8912.42 bcbs hmo Destruction of ovaries using an endoscope cpt 58670 8912.42 8912.42 3969.52 3969.52 20520.59 20520.59 17100.49 17100.49 O 8912.42 8912.42 bcbs pos Destruction of ovaries using an endoscope cpt 58670 8912.42 8912.42 3969.52 3969.52 20520.59 20520.59 17100.49 17100.49 O 8912.42 8912.42 bcbs ppo Destruction of ovaries using an endoscope cpt 58670 8912.42 8912.42 3969.52 3969.52 20520.59 20520.59 17100.49 17100.49 O 8912.42 8912.42 bcbs epo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 625.44 625.44 bcbs hmo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 625.44 625.44 bcbs hmo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 625.44 625.44 bcbs pos betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 625.44 625.44 bcbs ppo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 625.44 625.44 bcbs epo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 1619.11 1619.11 bcbs hmo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 1619.11 1619.11 bcbs hmo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 1619.11 1619.11 bcbs pos ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 1619.11 1619.11 bcbs ppo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 1619.11 1619.11 bcbs epo cefoxitin sodium injection cpt J0694 3621.48 3621.48 2076.66 2076.66 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs hmo cefoxitin sodium injection cpt J0694 3621.48 3621.48 2076.66 2076.66 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs hmo cefoxitin sodium injection cpt J0694 3621.48 3621.48 2076.66 2076.66 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs pos cefoxitin sodium injection cpt J0694 3621.48 3621.48 2076.66 2076.66 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs ppo cefoxitin sodium injection cpt J0694 3621.48 3621.48 2076.66 2076.66 20338.74 20338.74 16948.95 16948.95 O 3621.48 3621.48 bcbs epo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 6336.31 6336.31 bcbs hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 6336.31 6336.31 bcbs hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 6336.31 6336.31 bcbs pos cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 6336.31 6336.31 bcbs ppo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 6336.31 6336.31 bcbs epo Spinal tap for diagnosis cpt 62270 1296.62 1296.62 645.92 645.92 5996.98 5996.98 4997.48 4997.48 O 1036.13 1036.13 bcbs hmo Spinal tap for diagnosis cpt 62270 1296.62 1296.62 645.92 645.92 5996.98 5996.98 4997.48 4997.48 O 1036.13 1036.13 bcbs hmo Spinal tap for diagnosis cpt 62270 1296.62 1296.62 645.92 645.92 5996.98 5996.98 4997.48 4997.48 O 1036.13 1036.13 bcbs pos Spinal tap for diagnosis cpt 62270 1296.62 1296.62 645.92 645.92 5996.98 5996.98 4997.48 4997.48 O 1036.13 1036.13 bcbs ppo Spinal tap for diagnosis cpt 62270 1296.62 1296.62 645.92 645.92 5996.98 5996.98 4997.48 4997.48 O 1036.13 1036.13 bcbs epo Diagnostic spinal tap of lower spine using imaging guidance cpt 62328 1036.13 1036.13 553.72 553.72 1690.81 1690.81 1409.01 1409.01 O 1036.13 1036.13 bcbs hmo Diagnostic spinal tap of lower spine using imaging guidance cpt 62328 1036.13 1036.13 553.72 553.72 1690.81 1690.81 1409.01 1409.01 O 1036.13 1036.13 bcbs hmo Diagnostic spinal tap of lower spine using imaging guidance cpt 62328 1036.13 1036.13 553.72 553.72 1690.81 1690.81 1409.01 1409.01 O 1036.13 1036.13 bcbs pos Diagnostic spinal tap of lower spine using imaging guidance cpt 62328 1036.13 1036.13 553.72 553.72 1690.81 1690.81 1409.01 1409.01 O 1036.13 1036.13 bcbs ppo Diagnostic spinal tap of lower spine using imaging guidance cpt 62328 1036.13 1036.13 553.72 553.72 1690.81 1690.81 1409.01 1409.01 O 1036.13 1036.13 bcbs epo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4353.14 4353.14 bcbs hmo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4353.14 4353.14 bcbs hmo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4353.14 4353.14 bcbs pos leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4353.14 4353.14 bcbs ppo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4353.14 4353.14 bcbs epo calcium gluconate injection cpt J0610 2009.92 2009.92 1163.18 1163.18 8819.08 8819.08 7349.23 7349.23 O 2009.92 2009.92 bcbs hmo calcium gluconate injection cpt J0610 2009.92 2009.92 1163.18 1163.18 8819.08 8819.08 7349.23 7349.23 O 2009.92 2009.92 bcbs hmo calcium gluconate injection cpt J0610 2009.92 2009.92 1163.18 1163.18 8819.08 8819.08 7349.23 7349.23 O 2009.92 2009.92 bcbs pos calcium gluconate injection cpt J0610 2009.92 2009.92 1163.18 1163.18 8819.08 8819.08 7349.23 7349.23 O 2009.92 2009.92 bcbs ppo calcium gluconate injection cpt J0610 2009.92 2009.92 1163.18 1163.18 8819.08 8819.08 7349.23 7349.23 O 2009.92 2009.92 bcbs epo dicyclomine injection cpt J0500 516.37 516.37 380.4 380.4 7372.99 7372.99 6144.16 6144.16 O 516.37 516.37 bcbs hmo dicyclomine injection cpt J0500 516.37 516.37 380.4 380.4 7372.99 7372.99 6144.16 6144.16 O 516.37 516.37 bcbs hmo dicyclomine injection cpt J0500 516.37 516.37 380.4 380.4 7372.99 7372.99 6144.16 6144.16 O 516.37 516.37 bcbs pos dicyclomine injection cpt J0500 516.37 516.37 380.4 380.4 7372.99 7372.99 6144.16 6144.16 O 516.37 516.37 bcbs ppo dicyclomine injection cpt J0500 516.37 516.37 380.4 380.4 7372.99 7372.99 6144.16 6144.16 O 516.37 516.37 bcbs epo atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 1106.07 1106.07 bcbs hmo atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 1106.07 1106.07 bcbs hmo atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 1106.07 1106.07 bcbs pos atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 1106.07 1106.07 bcbs ppo atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 1106.07 1106.07 bcbs epo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 1180.35 1180.35 bcbs hmo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 1180.35 1180.35 bcbs hmo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 1180.35 1180.35 bcbs pos Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 1180.35 1180.35 bcbs ppo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 1180.35 1180.35 bcbs epo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 7532.57 7532.57 bcbs hmo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 7532.57 7532.57 bcbs hmo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 7532.57 7532.57 bcbs pos hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 7532.57 7532.57 bcbs ppo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 7532.57 7532.57 bcbs epo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 9785.8 9785.8 bcbs hmo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 9785.8 9785.8 bcbs hmo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 9785.8 9785.8 bcbs pos Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 9785.8 9785.8 bcbs ppo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 9785.8 9785.8 bcbs epo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 6436.14 6436.14 bcbs hmo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 6436.14 6436.14 bcbs hmo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 6436.14 6436.14 bcbs pos succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 6436.14 6436.14 bcbs ppo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 6436.14 6436.14 bcbs epo ampicillin sulbactam 1.5 gm cpt J0295 7147.22 7147.22 586.06 586.06 8236.51 8236.51 6863.76 6863.76 O 1002.03 1002.03 bcbs hmo ampicillin sulbactam 1.5 gm cpt J0295 7147.22 7147.22 586.06 586.06 8236.51 8236.51 6863.76 6863.76 O 1002.03 1002.03 bcbs hmo ampicillin sulbactam 1.5 gm cpt J0295 7147.22 7147.22 586.06 586.06 8236.51 8236.51 6863.76 6863.76 O 1002.03 1002.03 bcbs pos ampicillin sulbactam 1.5 gm cpt J0295 7147.22 7147.22 586.06 586.06 8236.51 8236.51 6863.76 6863.76 O 1002.03 1002.03 bcbs ppo ampicillin sulbactam 1.5 gm cpt J0295 7147.22 7147.22 586.06 586.06 8236.51 8236.51 6863.76 6863.76 O 1002.03 1002.03 bcbs epo ampicillin 500 mg inj cpt J0290 3073.87 3073.87 486.78 486.78 6558.29 6558.29 5465.24 5465.24 O 3073.87 3073.87 bcbs hmo ampicillin 500 mg inj cpt J0290 3073.87 3073.87 486.78 486.78 6558.29 6558.29 5465.24 5465.24 O 3073.87 3073.87 bcbs hmo ampicillin 500 mg inj cpt J0290 3073.87 3073.87 486.78 486.78 6558.29 6558.29 5465.24 5465.24 O 3073.87 3073.87 bcbs pos ampicillin 500 mg inj cpt J0290 3073.87 3073.87 486.78 486.78 6558.29 6558.29 5465.24 5465.24 O 3073.87 3073.87 bcbs ppo ampicillin 500 mg inj cpt J0290 3073.87 3073.87 486.78 486.78 6558.29 6558.29 5465.24 5465.24 O 3073.87 3073.87 bcbs epo amphotericin b liposome inj cpt J0289 3073.87 3073.87 3073.87 3073.87 15408.5 15408.5 12840.42 12840.42 O 3073.87 3073.87 bcbs hmo amphotericin b liposome inj cpt J0289 3073.87 3073.87 3073.87 3073.87 15408.5 15408.5 12840.42 12840.42 O 3073.87 3073.87 bcbs hmo amphotericin b liposome inj cpt J0289 3073.87 3073.87 3073.87 3073.87 15408.5 15408.5 12840.42 12840.42 O 3073.87 3073.87 bcbs pos amphotericin b liposome inj cpt J0289 3073.87 3073.87 3073.87 3073.87 15408.5 15408.5 12840.42 12840.42 O 3073.87 3073.87 bcbs ppo amphotericin b liposome inj cpt J0289 3073.87 3073.87 3073.87 3073.87 15408.5 15408.5 12840.42 12840.42 O 3073.87 3073.87 bcbs epo "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 10903.98 10903.98 bcbs hmo "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 10903.98 10903.98 bcbs hmo "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 10903.98 10903.98 bcbs pos "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 10903.98 10903.98 bcbs ppo "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 10903.98 10903.98 bcbs epo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 6354.01 6354.01 bcbs hmo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 6354.01 6354.01 bcbs hmo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 6354.01 6354.01 bcbs pos adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 6354.01 6354.01 bcbs ppo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 6354.01 6354.01 bcbs epo "Removal of lower spine bone and growth other than a tumor, extradural" cpt 63267 10903.98 10903.98 5214.5 5214.5 33315.5 33315.5 27762.92 27762.92 O 10903.98 10903.98 bcbs hmo "Removal of lower spine bone and growth other than a tumor, extradural" cpt 63267 10903.98 10903.98 5214.5 5214.5 33315.5 33315.5 27762.92 27762.92 O 10903.98 10903.98 bcbs hmo "Removal of lower spine bone and growth other than a tumor, extradural" cpt 63267 10903.98 10903.98 5214.5 5214.5 33315.5 33315.5 27762.92 27762.92 O 10903.98 10903.98 bcbs pos "Removal of lower spine bone and growth other than a tumor, extradural" cpt 63267 10903.98 10903.98 5214.5 5214.5 33315.5 33315.5 27762.92 27762.92 O 10903.98 10903.98 bcbs ppo "Removal of lower spine bone and growth other than a tumor, extradural" cpt 63267 10903.98 10903.98 5214.5 5214.5 33315.5 33315.5 27762.92 27762.92 O 10903.98 10903.98 bcbs epo "Implantation of spinal neurostimulator electrodes, accessed through the skin" cpt 63650 8962.99 8962.99 8962.99 8962.99 16176.48 16176.48 13480.4 13480.4 O 8962.99 8962.99 bcbs hmo "Implantation of spinal neurostimulator electrodes, accessed through the skin" cpt 63650 8962.99 8962.99 8962.99 8962.99 16176.48 16176.48 13480.4 13480.4 O 8962.99 8962.99 bcbs hmo "Implantation of spinal neurostimulator electrodes, accessed through the skin" cpt 63650 8962.99 8962.99 8962.99 8962.99 16176.48 16176.48 13480.4 13480.4 O 8962.99 8962.99 bcbs pos "Implantation of spinal neurostimulator electrodes, accessed through the skin" cpt 63650 8962.99 8962.99 8962.99 8962.99 16176.48 16176.48 13480.4 13480.4 O 8962.99 8962.99 bcbs ppo "Implantation of spinal neurostimulator electrodes, accessed through the skin" cpt 63650 8962.99 8962.99 8962.99 8962.99 16176.48 16176.48 13480.4 13480.4 O 8962.99 8962.99 bcbs epo Injection of anesthetic agent and/or steroid into trigeminal nerve of face cpt 64400 1202.31 1202.31 1202.31 1202.31 1442.77 1442.77 1202.31 1202.31 O 1202.31 1202.31 bcbs hmo Injection of anesthetic agent and/or steroid into trigeminal nerve of face cpt 64400 1202.31 1202.31 1202.31 1202.31 1442.77 1442.77 1202.31 1202.31 O 1202.31 1202.31 bcbs hmo Injection of anesthetic agent and/or steroid into trigeminal nerve of face cpt 64400 1202.31 1202.31 1202.31 1202.31 1442.77 1442.77 1202.31 1202.31 O 1202.31 1202.31 bcbs pos Injection of anesthetic agent and/or steroid into trigeminal nerve of face cpt 64400 1202.31 1202.31 1202.31 1202.31 1442.77 1442.77 1202.31 1202.31 O 1202.31 1202.31 bcbs ppo Injection of anesthetic agent and/or steroid into trigeminal nerve of face cpt 64400 1202.31 1202.31 1202.31 1202.31 1442.77 1442.77 1202.31 1202.31 O 1202.31 1202.31 bcbs epo acyclovir injection cpt J0133 3073.87 3073.87 1124.12 1124.12 8409.73 8409.73 7008.11 7008.11 O 3073.87 3073.87 bcbs hmo acyclovir injection cpt J0133 3073.87 3073.87 1124.12 1124.12 8409.73 8409.73 7008.11 7008.11 O 3073.87 3073.87 bcbs hmo acyclovir injection cpt J0133 3073.87 3073.87 1124.12 1124.12 8409.73 8409.73 7008.11 7008.11 O 3073.87 3073.87 bcbs pos acyclovir injection cpt J0133 3073.87 3073.87 1124.12 1124.12 8409.73 8409.73 7008.11 7008.11 O 3073.87 3073.87 bcbs ppo acyclovir injection cpt J0133 3073.87 3073.87 1124.12 1124.12 8409.73 8409.73 7008.11 7008.11 O 3073.87 3073.87 bcbs epo Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 12067.91 12067.91 bcbs hmo Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 12067.91 12067.91 bcbs hmo Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 12067.91 12067.91 bcbs pos Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 12067.91 12067.91 bcbs ppo Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 12067.91 12067.91 bcbs epo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 6476.33 6476.33 bcbs hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 6476.33 6476.33 bcbs hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 6476.33 6476.33 bcbs pos acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 6476.33 6476.33 bcbs ppo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 6476.33 6476.33 bcbs epo drug test def 15-21 classes cpt G0482 99 99 99 99 1503.49 1503.49 1252.91 1252.91 O 99 99 bcbs hmo drug test def 15-21 classes cpt G0482 99 99 99 99 1503.49 1503.49 1252.91 1252.91 O 99 99 bcbs hmo drug test def 15-21 classes cpt G0482 99 99 99 99 1503.49 1503.49 1252.91 1252.91 O 99 99 bcbs pos drug test def 15-21 classes cpt G0482 99 99 99 99 1503.49 1503.49 1252.91 1252.91 O 99 99 bcbs ppo drug test def 15-21 classes cpt G0482 99 99 99 99 1503.49 1503.49 1252.91 1252.91 O 99 99 bcbs epo drug test def 1-7 classes cpt G0480 1427.41 1427.41 961.2 961.2 5732.09 5732.09 4776.74 4776.74 O 961.2 961.2 bcbs hmo drug test def 1-7 classes cpt G0480 1427.41 1427.41 961.2 961.2 5732.09 5732.09 4776.74 4776.74 O 961.2 961.2 bcbs hmo drug test def 1-7 classes cpt G0480 1427.41 1427.41 961.2 961.2 5732.09 5732.09 4776.74 4776.74 O 961.2 961.2 bcbs pos drug test def 1-7 classes cpt G0480 1427.41 1427.41 961.2 961.2 5732.09 5732.09 4776.74 4776.74 O 961.2 961.2 bcbs ppo drug test def 1-7 classes cpt G0480 1427.41 1427.41 961.2 961.2 5732.09 5732.09 4776.74 4776.74 O 961.2 961.2 bcbs epo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 343.78 343.78 bcbs hmo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 343.78 343.78 bcbs hmo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 343.78 343.78 bcbs pos hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 343.78 343.78 bcbs ppo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 343.78 343.78 bcbs epo lev 3 hosp type b ed visit cpt G0382 533.3 533.3 533.3 533.3 2662.08 2662.08 2218.4 2218.4 O 533.3 533.3 bcbs hmo lev 3 hosp type b ed visit cpt G0382 533.3 533.3 533.3 533.3 2662.08 2662.08 2218.4 2218.4 O 533.3 533.3 bcbs hmo lev 3 hosp type b ed visit cpt G0382 533.3 533.3 533.3 533.3 2662.08 2662.08 2218.4 2218.4 O 533.3 533.3 bcbs pos lev 3 hosp type b ed visit cpt G0382 533.3 533.3 533.3 533.3 2662.08 2662.08 2218.4 2218.4 O 533.3 533.3 bcbs ppo lev 3 hosp type b ed visit cpt G0382 533.3 533.3 533.3 533.3 2662.08 2662.08 2218.4 2218.4 O 533.3 533.3 bcbs epo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1799.19 1799.19 bcbs hmo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1799.19 1799.19 bcbs hmo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1799.19 1799.19 bcbs pos "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1799.19 1799.19 bcbs ppo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1799.19 1799.19 bcbs epo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 2903.73 2903.73 bcbs hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 2903.73 2903.73 bcbs hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 2903.73 2903.73 bcbs pos hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 2903.73 2903.73 bcbs ppo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 2903.73 2903.73 bcbs epo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 312.75 312.75 bcbs hmo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 312.75 312.75 bcbs hmo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 312.75 312.75 bcbs pos ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 312.75 312.75 bcbs ppo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 312.75 312.75 bcbs epo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 1799.19 1799.19 bcbs hmo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 1799.19 1799.19 bcbs hmo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 1799.19 1799.19 bcbs pos "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 1799.19 1799.19 bcbs ppo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 1799.19 1799.19 bcbs epo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 1799.19 1799.19 bcbs hmo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 1799.19 1799.19 bcbs hmo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 1799.19 1799.19 bcbs pos "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 1799.19 1799.19 bcbs ppo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 1799.19 1799.19 bcbs epo elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 1387.03 1387.03 bcbs hmo elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 1387.03 1387.03 bcbs hmo elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 1387.03 1387.03 bcbs pos elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 1387.03 1387.03 bcbs ppo elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 1387.03 1387.03 bcbs epo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 384.61 384.61 bcbs hmo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 384.61 384.61 bcbs hmo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 384.61 384.61 bcbs pos "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 384.61 384.61 bcbs ppo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 384.61 384.61 bcbs epo Destruction of lower or sacral spinal facet joint nerves using imaging guidance cpt 64635 1803.46 1803.46 1391.28 1391.28 8020.78 8020.78 6683.98 6683.98 O 1803.46 1803.46 bcbs hmo Destruction of lower or sacral spinal facet joint nerves using imaging guidance cpt 64635 1803.46 1803.46 1391.28 1391.28 8020.78 8020.78 6683.98 6683.98 O 1803.46 1803.46 bcbs hmo Destruction of lower or sacral spinal facet joint nerves using imaging guidance cpt 64635 1803.46 1803.46 1391.28 1391.28 8020.78 8020.78 6683.98 6683.98 O 1803.46 1803.46 bcbs pos Destruction of lower or sacral spinal facet joint nerves using imaging guidance cpt 64635 1803.46 1803.46 1391.28 1391.28 8020.78 8020.78 6683.98 6683.98 O 1803.46 1803.46 bcbs ppo Destruction of lower or sacral spinal facet joint nerves using imaging guidance cpt 64635 1803.46 1803.46 1391.28 1391.28 8020.78 8020.78 6683.98 6683.98 O 1803.46 1803.46 bcbs epo Destruction of lower or sacral spinal facet joint nerves with imaging guidance cpt 64636 1803.46 1803.46 1391.28 1391.28 8021.77 8021.77 6684.81 6684.81 O 1803.46 1803.46 bcbs hmo Destruction of lower or sacral spinal facet joint nerves with imaging guidance cpt 64636 1803.46 1803.46 1391.28 1391.28 8021.77 8021.77 6684.81 6684.81 O 1803.46 1803.46 bcbs hmo Destruction of lower or sacral spinal facet joint nerves with imaging guidance cpt 64636 1803.46 1803.46 1391.28 1391.28 8021.77 8021.77 6684.81 6684.81 O 1803.46 1803.46 bcbs pos Destruction of lower or sacral spinal facet joint nerves with imaging guidance cpt 64636 1803.46 1803.46 1391.28 1391.28 8021.77 8021.77 6684.81 6684.81 O 1803.46 1803.46 bcbs ppo Destruction of lower or sacral spinal facet joint nerves with imaging guidance cpt 64636 1803.46 1803.46 1391.28 1391.28 8021.77 8021.77 6684.81 6684.81 O 1803.46 1803.46 bcbs epo inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 1055.98 1055.98 bcbs hmo inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 1055.98 1055.98 bcbs hmo inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 1055.98 1055.98 bcbs pos inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 1055.98 1055.98 bcbs ppo inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 1055.98 1055.98 bcbs epo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 4460.03 4460.03 bcbs hmo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 4460.03 4460.03 bcbs hmo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 4460.03 4460.03 bcbs pos Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 4460.03 4460.03 bcbs ppo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 4460.03 4460.03 bcbs epo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1382.14 1382.14 bcbs hmo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1382.14 1382.14 bcbs hmo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1382.14 1382.14 bcbs pos colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1382.14 1382.14 bcbs ppo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1382.14 1382.14 bcbs epo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 4350.3 4350.3 bcbs hmo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 4350.3 4350.3 bcbs hmo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 4350.3 4350.3 bcbs pos Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 4350.3 4350.3 bcbs ppo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 4350.3 4350.3 bcbs epo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 1372.47 1372.47 bcbs hmo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 1372.47 1372.47 bcbs hmo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 1372.47 1372.47 bcbs pos colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 1372.47 1372.47 bcbs ppo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 1372.47 1372.47 bcbs epo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 95.83 95.83 bcbs hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 95.83 95.83 bcbs hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 95.83 95.83 bcbs pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 95.83 95.83 bcbs ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 95.83 95.83 bcbs epo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 3029.49 3029.49 bcbs hmo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 3029.49 3029.49 bcbs hmo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 3029.49 3029.49 bcbs pos admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 3029.49 3029.49 bcbs ppo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 3029.49 3029.49 bcbs epo Removal of embedded foreign body in eyelid cpt 67938 944.79 944.79 944.79 944.79 1133.75 1133.75 944.79 944.79 O 944.79 944.79 bcbs hmo Removal of embedded foreign body in eyelid cpt 67938 944.79 944.79 944.79 944.79 1133.75 1133.75 944.79 944.79 O 944.79 944.79 bcbs hmo Removal of embedded foreign body in eyelid cpt 67938 944.79 944.79 944.79 944.79 1133.75 1133.75 944.79 944.79 O 944.79 944.79 bcbs pos Removal of embedded foreign body in eyelid cpt 67938 944.79 944.79 944.79 944.79 1133.75 1133.75 944.79 944.79 O 944.79 944.79 bcbs ppo Removal of embedded foreign body in eyelid cpt 67938 944.79 944.79 944.79 944.79 1133.75 1133.75 944.79 944.79 O 944.79 944.79 bcbs epo Removal of impacted ear wax by washing cpt 69209 409.91 409.91 409.91 409.91 1077.82 1077.82 898.18 898.18 O 409.91 409.91 bcbs hmo Removal of impacted ear wax by washing cpt 69209 409.91 409.91 409.91 409.91 1077.82 1077.82 898.18 898.18 O 409.91 409.91 bcbs hmo Removal of impacted ear wax by washing cpt 69209 409.91 409.91 409.91 409.91 1077.82 1077.82 898.18 898.18 O 409.91 409.91 bcbs pos Removal of impacted ear wax by washing cpt 69209 409.91 409.91 409.91 409.91 1077.82 1077.82 898.18 898.18 O 409.91 409.91 bcbs ppo Removal of impacted ear wax by washing cpt 69209 409.91 409.91 409.91 409.91 1077.82 1077.82 898.18 898.18 O 409.91 409.91 bcbs epo "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 70.78 70.78 bcbs hmo "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 70.78 70.78 bcbs hmo "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 70.78 70.78 bcbs pos "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 70.78 70.78 bcbs ppo "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 70.78 70.78 bcbs epo "X-ray of paranasal sinus, complete, minimum of 3 views" cpt 70220 151.6 151.6 21.76 21.76 368.88 368.88 307.4 307.4 O 151.6 151.6 bcbs hmo "X-ray of paranasal sinus, complete, minimum of 3 views" cpt 70220 151.6 151.6 21.76 21.76 368.88 368.88 307.4 307.4 O 151.6 151.6 bcbs hmo "X-ray of paranasal sinus, complete, minimum of 3 views" cpt 70220 151.6 151.6 21.76 21.76 368.88 368.88 307.4 307.4 O 151.6 151.6 bcbs pos "X-ray of paranasal sinus, complete, minimum of 3 views" cpt 70220 151.6 151.6 21.76 21.76 368.88 368.88 307.4 307.4 O 151.6 151.6 bcbs ppo "X-ray of paranasal sinus, complete, minimum of 3 views" cpt 70220 151.6 151.6 21.76 21.76 368.88 368.88 307.4 307.4 O 151.6 151.6 bcbs epo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1017.53 1017.53 bcbs hmo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1017.53 1017.53 bcbs hmo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1017.53 1017.53 bcbs pos "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1017.53 1017.53 bcbs ppo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 1017.53 1017.53 bcbs epo X-ray of soft tissue of neck cpt 70360 65.69 65.69 18.36 18.36 244.22 244.22 203.52 203.52 O 65.69 65.69 bcbs hmo X-ray of soft tissue of neck cpt 70360 65.69 65.69 18.36 18.36 244.22 244.22 203.52 203.52 O 65.69 65.69 bcbs hmo X-ray of soft tissue of neck cpt 70360 65.69 65.69 18.36 18.36 244.22 244.22 203.52 203.52 O 65.69 65.69 bcbs pos X-ray of soft tissue of neck cpt 70360 65.69 65.69 18.36 18.36 244.22 244.22 203.52 203.52 O 65.69 65.69 bcbs ppo X-ray of soft tissue of neck cpt 70360 65.69 65.69 18.36 18.36 244.22 244.22 203.52 203.52 O 65.69 65.69 bcbs epo "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 4436.99 4436.99 bcbs hmo "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 4436.99 4436.99 bcbs hmo "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 4436.99 4436.99 bcbs pos "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 4436.99 4436.99 bcbs ppo "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 4436.99 4436.99 bcbs epo "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 11766.2 11766.2 bcbs hmo "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 11766.2 11766.2 bcbs hmo "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 11766.2 11766.2 bcbs pos "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 11766.2 11766.2 bcbs ppo "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 11766.2 11766.2 bcbs epo "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 8848.19 8848.19 bcbs hmo "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 8848.19 8848.19 bcbs hmo "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 8848.19 8848.19 bcbs pos "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 8848.19 8848.19 bcbs ppo "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 8848.19 8848.19 bcbs epo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 482.16 482.16 bcbs hmo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 482.16 482.16 bcbs hmo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 482.16 482.16 bcbs pos CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 482.16 482.16 bcbs ppo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 482.16 482.16 bcbs epo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 8239.98 8239.98 bcbs hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 8239.98 8239.98 bcbs hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 8239.98 8239.98 bcbs pos "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 8239.98 8239.98 bcbs ppo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 8239.98 8239.98 bcbs epo CT scan of cranial cavity with contrast cpt 70481 405.43 405.43 405.43 405.43 1507.32 1507.32 1256.1 1256.1 O 405.43 405.43 bcbs hmo CT scan of cranial cavity with contrast cpt 70481 405.43 405.43 405.43 405.43 1507.32 1507.32 1256.1 1256.1 O 405.43 405.43 bcbs hmo CT scan of cranial cavity with contrast cpt 70481 405.43 405.43 405.43 405.43 1507.32 1507.32 1256.1 1256.1 O 405.43 405.43 bcbs pos CT scan of cranial cavity with contrast cpt 70481 405.43 405.43 405.43 405.43 1507.32 1507.32 1256.1 1256.1 O 405.43 405.43 bcbs ppo CT scan of cranial cavity with contrast cpt 70481 405.43 405.43 405.43 405.43 1507.32 1507.32 1256.1 1256.1 O 405.43 405.43 bcbs epo CT scan of cranial cavity before and after contrast cpt 70482 393.66 393.66 393.66 393.66 2255.82 2255.82 1879.85 1879.85 O 393.66 393.66 bcbs hmo CT scan of cranial cavity before and after contrast cpt 70482 393.66 393.66 393.66 393.66 2255.82 2255.82 1879.85 1879.85 O 393.66 393.66 bcbs hmo CT scan of cranial cavity before and after contrast cpt 70482 393.66 393.66 393.66 393.66 2255.82 2255.82 1879.85 1879.85 O 393.66 393.66 bcbs pos CT scan of cranial cavity before and after contrast cpt 70482 393.66 393.66 393.66 393.66 2255.82 2255.82 1879.85 1879.85 O 393.66 393.66 bcbs ppo CT scan of cranial cavity before and after contrast cpt 70482 393.66 393.66 393.66 393.66 2255.82 2255.82 1879.85 1879.85 O 393.66 393.66 bcbs epo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 4087.43 4087.43 bcbs hmo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 4087.43 4087.43 bcbs hmo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 4087.43 4087.43 bcbs pos "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 4087.43 4087.43 bcbs ppo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 4087.43 4087.43 bcbs epo CT scan of face with contrast cpt 70487 408.55 408.55 92.8 92.8 1507.32 1507.32 1256.1 1256.1 O 340.48 340.48 bcbs hmo CT scan of face with contrast cpt 70487 408.55 408.55 92.8 92.8 1507.32 1507.32 1256.1 1256.1 O 340.48 340.48 bcbs hmo CT scan of face with contrast cpt 70487 408.55 408.55 92.8 92.8 1507.32 1507.32 1256.1 1256.1 O 340.48 340.48 bcbs pos CT scan of face with contrast cpt 70487 408.55 408.55 92.8 92.8 1507.32 1507.32 1256.1 1256.1 O 340.48 340.48 bcbs ppo CT scan of face with contrast cpt 70487 408.55 408.55 92.8 92.8 1507.32 1507.32 1256.1 1256.1 O 340.48 340.48 bcbs epo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 186.17 186.17 bcbs hmo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 186.17 186.17 bcbs hmo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 186.17 186.17 bcbs pos CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 186.17 186.17 bcbs ppo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 186.17 186.17 bcbs epo "catheter, ablation" cpt C1886 6142.86 6142.86 4006.52 4006.52 26466.79 26466.79 22055.66 22055.66 O 6142.86 6142.86 bcbs hmo "catheter, ablation" cpt C1886 6142.86 6142.86 4006.52 4006.52 26466.79 26466.79 22055.66 22055.66 O 6142.86 6142.86 bcbs hmo "catheter, ablation" cpt C1886 6142.86 6142.86 4006.52 4006.52 26466.79 26466.79 22055.66 22055.66 O 6142.86 6142.86 bcbs pos "catheter, ablation" cpt C1886 6142.86 6142.86 4006.52 4006.52 26466.79 26466.79 22055.66 22055.66 O 6142.86 6142.86 bcbs ppo "catheter, ablation" cpt C1886 6142.86 6142.86 4006.52 4006.52 26466.79 26466.79 22055.66 22055.66 O 6142.86 6142.86 bcbs epo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8539.57 8539.57 bcbs hmo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8539.57 8539.57 bcbs hmo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8539.57 8539.57 bcbs pos embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8539.57 8539.57 bcbs ppo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8539.57 8539.57 bcbs epo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 381.69 381.69 bcbs hmo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 381.69 381.69 bcbs hmo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 381.69 381.69 bcbs pos CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 381.69 381.69 bcbs ppo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 381.69 381.69 bcbs epo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 8922.15 8922.15 bcbs hmo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 8922.15 8922.15 bcbs hmo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 8922.15 8922.15 bcbs pos "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 8922.15 8922.15 bcbs ppo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 8922.15 8922.15 bcbs epo CT scan of neck before and after contrast cpt 70492 697.54 697.54 161.43 161.43 2148.41 2148.41 1790.34 1790.34 O 697.54 697.54 bcbs hmo CT scan of neck before and after contrast cpt 70492 697.54 697.54 161.43 161.43 2148.41 2148.41 1790.34 1790.34 O 697.54 697.54 bcbs hmo CT scan of neck before and after contrast cpt 70492 697.54 697.54 161.43 161.43 2148.41 2148.41 1790.34 1790.34 O 697.54 697.54 bcbs pos CT scan of neck before and after contrast cpt 70492 697.54 697.54 161.43 161.43 2148.41 2148.41 1790.34 1790.34 O 697.54 697.54 bcbs ppo CT scan of neck before and after contrast cpt 70492 697.54 697.54 161.43 161.43 2148.41 2148.41 1790.34 1790.34 O 697.54 697.54 bcbs epo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 4400.88 4400.88 bcbs hmo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 4400.88 4400.88 bcbs hmo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 4400.88 4400.88 bcbs pos "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 4400.88 4400.88 bcbs ppo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 4400.88 4400.88 bcbs epo CT scan of blood vessel of head with contrast cpt 70496 465.78 465.78 159.8 159.8 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs hmo CT scan of blood vessel of head with contrast cpt 70496 465.78 465.78 159.8 159.8 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs hmo CT scan of blood vessel of head with contrast cpt 70496 465.78 465.78 159.8 159.8 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs pos CT scan of blood vessel of head with contrast cpt 70496 465.78 465.78 159.8 159.8 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs ppo CT scan of blood vessel of head with contrast cpt 70496 465.78 465.78 159.8 159.8 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs epo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 7519.16 7519.16 bcbs hmo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 7519.16 7519.16 bcbs hmo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 7519.16 7519.16 bcbs pos mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 7519.16 7519.16 bcbs ppo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 7519.16 7519.16 bcbs epo joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 7889.33 7889.33 bcbs hmo joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 7889.33 7889.33 bcbs hmo joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 7889.33 7889.33 bcbs pos joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 7889.33 7889.33 bcbs ppo joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 7889.33 7889.33 bcbs epo CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs hmo CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs hmo CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs pos CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs ppo CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 465.78 465.78 bcbs epo "MRI scan bones of the eye, face, and/or neck" cpt 70540 1258.88 1258.88 1258.88 1258.88 1901.64 1901.64 1584.7 1584.7 O 1258.88 1258.88 bcbs hmo "MRI scan bones of the eye, face, and/or neck" cpt 70540 1258.88 1258.88 1258.88 1258.88 1901.64 1901.64 1584.7 1584.7 O 1258.88 1258.88 bcbs hmo "MRI scan bones of the eye, face, and/or neck" cpt 70540 1258.88 1258.88 1258.88 1258.88 1901.64 1901.64 1584.7 1584.7 O 1258.88 1258.88 bcbs pos "MRI scan bones of the eye, face, and/or neck" cpt 70540 1258.88 1258.88 1258.88 1258.88 1901.64 1901.64 1584.7 1584.7 O 1258.88 1258.88 bcbs ppo "MRI scan bones of the eye, face, and/or neck" cpt 70540 1258.88 1258.88 1258.88 1258.88 1901.64 1901.64 1584.7 1584.7 O 1258.88 1258.88 bcbs epo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 8239.98 8239.98 bcbs hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 8239.98 8239.98 bcbs hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 8239.98 8239.98 bcbs pos guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 8239.98 8239.98 bcbs ppo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 8239.98 8239.98 bcbs epo "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 481.31 481.31 bcbs hmo "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 481.31 481.31 bcbs hmo "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 481.31 481.31 bcbs pos "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 481.31 481.31 bcbs ppo "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 481.31 481.31 bcbs epo MRA scan of neck blood vessels cpt 70547 559.22 559.22 559.22 559.22 3060.43 3060.43 2550.36 2550.36 O 559.22 559.22 bcbs hmo MRA scan of neck blood vessels cpt 70547 559.22 559.22 559.22 559.22 3060.43 3060.43 2550.36 2550.36 O 559.22 559.22 bcbs hmo MRA scan of neck blood vessels cpt 70547 559.22 559.22 559.22 559.22 3060.43 3060.43 2550.36 2550.36 O 559.22 559.22 bcbs pos MRA scan of neck blood vessels cpt 70547 559.22 559.22 559.22 559.22 3060.43 3060.43 2550.36 2550.36 O 559.22 559.22 bcbs ppo MRA scan of neck blood vessels cpt 70547 559.22 559.22 559.22 559.22 3060.43 3060.43 2550.36 2550.36 O 559.22 559.22 bcbs epo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 811.86 811.86 bcbs hmo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 811.86 811.86 bcbs hmo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 811.86 811.86 bcbs pos MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 811.86 811.86 bcbs ppo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 811.86 811.86 bcbs epo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 4681.97 4681.97 bcbs hmo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 4681.97 4681.97 bcbs hmo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 4681.97 4681.97 bcbs pos "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 4681.97 4681.97 bcbs ppo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 4681.97 4681.97 bcbs epo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2405.95 2405.95 bcbs hmo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2405.95 2405.95 bcbs hmo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2405.95 2405.95 bcbs pos "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2405.95 2405.95 bcbs ppo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2405.95 2405.95 bcbs epo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 2407.34 2407.34 bcbs hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 2407.34 2407.34 bcbs hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 2407.34 2407.34 bcbs pos "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 2407.34 2407.34 bcbs ppo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 2407.34 2407.34 bcbs epo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 7600.98 7600.98 bcbs hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 7600.98 7600.98 bcbs hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 7600.98 7600.98 bcbs pos "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 7600.98 7600.98 bcbs ppo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 7600.98 7600.98 bcbs epo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1251.77 1251.77 bcbs hmo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1251.77 1251.77 bcbs hmo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1251.77 1251.77 bcbs pos "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1251.77 1251.77 bcbs ppo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 1251.77 1251.77 bcbs epo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 66.4 66.4 bcbs hmo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 66.4 66.4 bcbs hmo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 66.4 66.4 bcbs pos "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 66.4 66.4 bcbs ppo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 66.4 66.4 bcbs epo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 4483.23 4483.23 bcbs hmo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 4483.23 4483.23 bcbs hmo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 4483.23 4483.23 bcbs pos tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 4483.23 4483.23 bcbs ppo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 4483.23 4483.23 bcbs epo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 1195.84 1195.84 bcbs hmo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 1195.84 1195.84 bcbs hmo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 1195.84 1195.84 bcbs pos tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 1195.84 1195.84 bcbs ppo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 1195.84 1195.84 bcbs epo "i131 iodide cap, rx" cpt A9517 1852.9 1852.9 713.83 713.83 4871.82 4871.82 4059.85 4059.85 O 713.83 713.83 bcbs hmo "i131 iodide cap, rx" cpt A9517 1852.9 1852.9 713.83 713.83 4871.82 4871.82 4059.85 4059.85 O 713.83 713.83 bcbs hmo "i131 iodide cap, rx" cpt A9517 1852.9 1852.9 713.83 713.83 4871.82 4871.82 4059.85 4059.85 O 713.83 713.83 bcbs pos "i131 iodide cap, rx" cpt A9517 1852.9 1852.9 713.83 713.83 4871.82 4871.82 4059.85 4059.85 O 713.83 713.83 bcbs ppo "i131 iodide cap, rx" cpt A9517 1852.9 1852.9 713.83 713.83 4871.82 4871.82 4059.85 4059.85 O 713.83 713.83 bcbs epo iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 1025.33 1025.33 bcbs hmo iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 1025.33 1025.33 bcbs hmo iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 1025.33 1025.33 bcbs pos iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 1025.33 1025.33 bcbs ppo iodine i-123 sod iodide mic cpt A9516 1025.33 1025.33 322.26 322.26 1796.06 1796.06 1496.72 1496.72 O 1025.33 1025.33 bcbs epo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 88.13 88.13 bcbs hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 88.13 88.13 bcbs hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 88.13 88.13 bcbs pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 88.13 88.13 bcbs ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 88.13 88.13 bcbs epo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 747.74 747.74 bcbs hmo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 747.74 747.74 bcbs hmo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 747.74 747.74 bcbs pos tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 747.74 747.74 bcbs ppo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 747.74 747.74 bcbs epo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1335.61 1335.61 bcbs hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1335.61 1335.61 bcbs hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1335.61 1335.61 bcbs pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1335.61 1335.61 bcbs ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1335.61 1335.61 bcbs epo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 616.41 616.41 bcbs hmo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 616.41 616.41 bcbs hmo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 616.41 616.41 bcbs pos alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 616.41 616.41 bcbs ppo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 616.41 616.41 bcbs epo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 157.17 157.17 bcbs hmo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 157.17 157.17 bcbs hmo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 157.17 157.17 bcbs pos "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 157.17 157.17 bcbs ppo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 157.17 157.17 bcbs epo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 725.19 725.19 bcbs hmo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 725.19 725.19 bcbs hmo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 725.19 725.19 bcbs pos alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 725.19 725.19 bcbs ppo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 725.19 725.19 bcbs epo Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 27.09 27.09 bcbs hmo Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 27.09 27.09 bcbs hmo Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 27.09 27.09 bcbs pos Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 27.09 27.09 bcbs ppo Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 27.09 27.09 bcbs epo implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 8915.14 8915.14 bcbs hmo implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 8915.14 8915.14 bcbs hmo implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 8915.14 8915.14 bcbs pos implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 8915.14 8915.14 bcbs ppo implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 8915.14 8915.14 bcbs epo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 70.9 70.9 bcbs hmo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 70.9 70.9 bcbs hmo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 70.9 70.9 bcbs pos "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 70.9 70.9 bcbs ppo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 70.9 70.9 bcbs epo "X-ray of both sides of the ribs, 3 views" cpt 71110 36.25 36.25 35.5 35.5 515.16 515.16 429.3 429.3 O 35.5 35.5 bcbs hmo "X-ray of both sides of the ribs, 3 views" cpt 71110 36.25 36.25 35.5 35.5 515.16 515.16 429.3 429.3 O 35.5 35.5 bcbs hmo "X-ray of both sides of the ribs, 3 views" cpt 71110 36.25 36.25 35.5 35.5 515.16 515.16 429.3 429.3 O 35.5 35.5 bcbs pos "X-ray of both sides of the ribs, 3 views" cpt 71110 36.25 36.25 35.5 35.5 515.16 515.16 429.3 429.3 O 35.5 35.5 bcbs ppo "X-ray of both sides of the ribs, 3 views" cpt 71110 36.25 36.25 35.5 35.5 515.16 515.16 429.3 429.3 O 35.5 35.5 bcbs epo "X-ray of breast bone, minimum of 2 views" cpt 71120 119.99 119.99 17.76 17.76 249.31 249.31 207.76 207.76 O 119.99 119.99 bcbs hmo "X-ray of breast bone, minimum of 2 views" cpt 71120 119.99 119.99 17.76 17.76 249.31 249.31 207.76 207.76 O 119.99 119.99 bcbs hmo "X-ray of breast bone, minimum of 2 views" cpt 71120 119.99 119.99 17.76 17.76 249.31 249.31 207.76 207.76 O 119.99 119.99 bcbs pos "X-ray of breast bone, minimum of 2 views" cpt 71120 119.99 119.99 17.76 17.76 249.31 249.31 207.76 207.76 O 119.99 119.99 bcbs ppo "X-ray of breast bone, minimum of 2 views" cpt 71120 119.99 119.99 17.76 17.76 249.31 249.31 207.76 207.76 O 119.99 119.99 bcbs epo als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2862 2862 bcbs hmo als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2862 2862 bcbs hmo als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2862 2862 bcbs pos als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2862 2862 bcbs ppo als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2862 2862 bcbs epo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 2862 2862 bcbs hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 2862 2862 bcbs hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 2862 2862 bcbs pos ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 2862 2862 bcbs ppo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 2862 2862 bcbs epo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 16230.79 16230.79 bcbs hmo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 16230.79 16230.79 bcbs hmo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 16230.79 16230.79 bcbs pos intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 16230.79 16230.79 bcbs ppo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 16230.79 16230.79 bcbs epo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 482.16 482.16 bcbs hmo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 482.16 482.16 bcbs hmo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 482.16 482.16 bcbs pos CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 482.16 482.16 bcbs ppo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 482.16 482.16 bcbs epo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 10.92 10.92 bcbs hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 10.92 10.92 bcbs hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 10.92 10.92 bcbs pos "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 10.92 10.92 bcbs ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 10.92 10.92 bcbs epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 11.48 11.48 bcbs hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 11.48 11.48 bcbs hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 11.48 11.48 bcbs pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 11.48 11.48 bcbs ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 11.48 11.48 bcbs epo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 396.78 396.78 bcbs hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 396.78 396.78 bcbs hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 396.78 396.78 bcbs pos CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 396.78 396.78 bcbs ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 396.78 396.78 bcbs epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 34.46 34.46 bcbs hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 34.46 34.46 bcbs hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 34.46 34.46 bcbs pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 34.46 34.46 bcbs ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 34.46 34.46 bcbs epo CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 808.13 808.13 bcbs hmo CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 808.13 808.13 bcbs hmo CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 808.13 808.13 bcbs pos CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 808.13 808.13 bcbs ppo CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 808.13 808.13 bcbs epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 26.73 26.73 bcbs hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 26.73 26.73 bcbs hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 26.73 26.73 bcbs pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 26.73 26.73 bcbs ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 26.73 26.73 bcbs epo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 19.96 19.96 bcbs hmo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 19.96 19.96 bcbs hmo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 19.96 19.96 bcbs pos "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 19.96 19.96 bcbs ppo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 19.96 19.96 bcbs epo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 621.12 621.12 bcbs hmo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 621.12 621.12 bcbs hmo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 621.12 621.12 bcbs pos CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 621.12 621.12 bcbs ppo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 621.12 621.12 bcbs epo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 4.32 4.32 bcbs hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 4.32 4.32 bcbs hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 4.32 4.32 bcbs pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 4.32 4.32 bcbs ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 4.32 4.32 bcbs epo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 72.81 72.81 bcbs hmo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 72.81 72.81 bcbs hmo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 72.81 72.81 bcbs pos "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 72.81 72.81 bcbs ppo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 72.81 72.81 bcbs epo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 bcbs hmo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 bcbs hmo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 bcbs pos Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 bcbs ppo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 21.26 21.26 bcbs epo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 21.16 21.16 bcbs hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 21.16 21.16 bcbs hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 21.16 21.16 bcbs pos "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 21.16 21.16 bcbs ppo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 21.16 21.16 bcbs epo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 138.45 138.45 bcbs hmo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 138.45 138.45 bcbs hmo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 138.45 138.45 bcbs pos "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 138.45 138.45 bcbs ppo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 138.45 138.45 bcbs epo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 18.76 18.76 bcbs hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 18.76 18.76 bcbs hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 18.76 18.76 bcbs pos Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 18.76 18.76 bcbs ppo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 18.76 18.76 bcbs epo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 17.97 17.97 bcbs hmo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 17.97 17.97 bcbs hmo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 17.97 17.97 bcbs pos Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 17.97 17.97 bcbs ppo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 17.97 17.97 bcbs epo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 65.62 65.62 bcbs hmo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 65.62 65.62 bcbs hmo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 65.62 65.62 bcbs pos "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 65.62 65.62 bcbs ppo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 65.62 65.62 bcbs epo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 134.26 134.26 bcbs hmo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 134.26 134.26 bcbs hmo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 134.26 134.26 bcbs pos "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 134.26 134.26 bcbs ppo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 134.26 134.26 bcbs epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 26.35 26.35 bcbs hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 26.35 26.35 bcbs hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 26.35 26.35 bcbs pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 26.35 26.35 bcbs ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 26.35 26.35 bcbs epo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 25.05 25.05 bcbs hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 25.05 25.05 bcbs hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 25.05 25.05 bcbs pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 25.05 25.05 bcbs ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 25.05 25.05 bcbs epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 21.35 21.35 bcbs hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 21.35 21.35 bcbs hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 21.35 21.35 bcbs pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 21.35 21.35 bcbs ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 21.35 21.35 bcbs epo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 77.24 77.24 bcbs hmo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 77.24 77.24 bcbs hmo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 77.24 77.24 bcbs pos "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 77.24 77.24 bcbs ppo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 77.24 77.24 bcbs epo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 61.44 61.44 bcbs hmo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 61.44 61.44 bcbs hmo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 61.44 61.44 bcbs pos "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 61.44 61.44 bcbs ppo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 61.44 61.44 bcbs epo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 529.29 529.29 bcbs hmo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 529.29 529.29 bcbs hmo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 529.29 529.29 bcbs pos "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 529.29 529.29 bcbs ppo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 529.29 529.29 bcbs epo "X-ray of spine, entire middle and lower spine, 1 view" cpt 72081 81.3 81.3 23.65 23.65 230.23 230.23 191.86 191.86 O 81.3 81.3 bcbs hmo "X-ray of spine, entire middle and lower spine, 1 view" cpt 72081 81.3 81.3 23.65 23.65 230.23 230.23 191.86 191.86 O 81.3 81.3 bcbs hmo "X-ray of spine, entire middle and lower spine, 1 view" cpt 72081 81.3 81.3 23.65 23.65 230.23 230.23 191.86 191.86 O 81.3 81.3 bcbs pos "X-ray of spine, entire middle and lower spine, 1 view" cpt 72081 81.3 81.3 23.65 23.65 230.23 230.23 191.86 191.86 O 81.3 81.3 bcbs ppo "X-ray of spine, entire middle and lower spine, 1 view" cpt 72081 81.3 81.3 23.65 23.65 230.23 230.23 191.86 191.86 O 81.3 81.3 bcbs epo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 616.41 616.41 bcbs hmo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 616.41 616.41 bcbs hmo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 616.41 616.41 bcbs pos "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 616.41 616.41 bcbs ppo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 616.41 616.41 bcbs epo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2526.95 2526.95 bcbs hmo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2526.95 2526.95 bcbs hmo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2526.95 2526.95 bcbs pos Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2526.95 2526.95 bcbs ppo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 2526.95 2526.95 bcbs epo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 116.63 116.63 bcbs hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 116.63 116.63 bcbs hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 116.63 116.63 bcbs pos "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 116.63 116.63 bcbs ppo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 116.63 116.63 bcbs epo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1543.69 1543.69 bcbs hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1543.69 1543.69 bcbs hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1543.69 1543.69 bcbs pos Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1543.69 1543.69 bcbs ppo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1543.69 1543.69 bcbs epo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 178.54 178.54 bcbs hmo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 178.54 178.54 bcbs hmo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 178.54 178.54 bcbs pos X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 178.54 178.54 bcbs ppo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 178.54 178.54 bcbs epo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1517.61 1517.61 bcbs hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1517.61 1517.61 bcbs hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1517.61 1517.61 bcbs pos Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1517.61 1517.61 bcbs ppo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1517.61 1517.61 bcbs epo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1662 1662 bcbs hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1662 1662 bcbs hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1662 1662 bcbs pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1662 1662 bcbs ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1662 1662 bcbs epo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 1810.27 1810.27 bcbs hmo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 1810.27 1810.27 bcbs hmo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 1810.27 1810.27 bcbs pos "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 1810.27 1810.27 bcbs ppo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 1810.27 1810.27 bcbs epo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 337.48 337.48 bcbs hmo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 337.48 337.48 bcbs hmo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 337.48 337.48 bcbs pos CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 337.48 337.48 bcbs ppo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 337.48 337.48 bcbs epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 1375.89 1375.89 bcbs medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 1375.89 1375.89 bcbs medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1934.02 1934.02 bcbs medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1934.02 1934.02 bcbs medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 2685.64 2685.64 bcbs medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 2685.64 2685.64 bcbs medicare advantage ppo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 482.16 482.16 bcbs medicare advantage pos CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 482.16 482.16 bcbs medicare advantage ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 54.9 54.9 bcbs medicare advantage pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 54.9 54.9 bcbs medicare advantage ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 bcbs medicare advantage pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 bcbs medicare advantage ppo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 49.35 49.35 bcbs medicare advantage pos Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 49.35 49.35 bcbs medicare advantage ppo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 32.65 32.65 bcbs medicare advantage pos "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 32.65 32.65 bcbs medicare advantage ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 7.61 7.61 bcbs medicare advantage pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 7.61 7.61 bcbs medicare advantage ppo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 12.87 12.87 bcbs medicare advantage pos Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 12.87 12.87 bcbs medicare advantage ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 22.82 22.82 bcbs medicare advantage pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 22.82 22.82 bcbs medicare advantage ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 23.26 23.26 bcbs medicare advantage pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 23.26 23.26 bcbs medicare advantage ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 21.47 21.47 bcbs medicare advantage pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 21.47 21.47 bcbs medicare advantage ppo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 31.53 31.53 bcbs medicare advantage pos "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 31.53 31.53 bcbs medicare advantage ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1934.02 1934.02 bcbs medicare advantage pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1934.02 1934.02 bcbs medicare advantage ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 10.09 10.09 bcbs medicare advantage pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 10.09 10.09 bcbs medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1934.02 1934.02 bcbs medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1934.02 1934.02 bcbs medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1108.98 1108.98 bcbs medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1108.98 1108.98 bcbs medicare advantage ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1934.02 1934.02 bcbs medicare advantage pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1934.02 1934.02 bcbs medicare advantage ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1934.02 1934.02 bcbs medicare advantage pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1934.02 1934.02 bcbs medicare advantage ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 23.62 23.62 bcbs medicare advantage pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 23.62 23.62 bcbs medicare advantage ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 98.86 98.86 bcbs medicare advantage pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 98.86 98.86 bcbs medicare advantage ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 51.42 51.42 bcbs medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 51.42 51.42 bcbs medicare advantage ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.12 13.12 bcbs medicare advantage pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.12 13.12 bcbs medicare advantage ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 94.59 94.59 bcbs medicare advantage pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 94.59 94.59 bcbs medicare advantage ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 45.56 45.56 bcbs medicare advantage pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 45.56 45.56 bcbs medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 44.06 44.06 bcbs medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 44.06 44.06 bcbs medicare advantage ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 12.76 12.76 bcbs medicare advantage pos "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 12.76 12.76 bcbs medicare advantage ppo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1934.02 1934.02 bcbs medicare advantage pos tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1934.02 1934.02 bcbs medicare advantage ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1108.98 1108.98 bcbs medicare advantage pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1108.98 1108.98 bcbs medicare advantage ppo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1934.02 1934.02 bcbs medicare advantage pos hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1934.02 1934.02 bcbs medicare advantage ppo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1934.02 1934.02 bcbs medicare advantage pos inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1934.02 1934.02 bcbs medicare advantage ppo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1934.02 1934.02 bcbs medicare advantage pos regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1934.02 1934.02 bcbs medicare advantage ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1108.98 1108.98 bcbs medicare advantage pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1108.98 1108.98 bcbs medicare advantage ppo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 1934.02 1934.02 bcbs medicare advantage pos normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 1934.02 1934.02 bcbs medicare advantage ppo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1934.02 1934.02 bcbs medicare advantage pos General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1934.02 1934.02 bcbs medicare advantage ppo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 1934.02 1934.02 bcbs medicare advantage pos General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 1934.02 1934.02 bcbs medicare advantage ppo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 2685.64 2685.64 bcbs medicare advantage pos General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 2685.64 2685.64 bcbs medicare advantage ppo Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 2685.64 2685.64 bcbs medicare advantage pos Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 2685.64 2685.64 bcbs medicare advantage ppo Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 139.32 139.32 bcbs medicare advantage pos Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 139.32 139.32 bcbs medicare advantage ppo Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 2685.64 2685.64 bcbs medicare advantage pos Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 2685.64 2685.64 bcbs medicare advantage ppo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 2685.64 2685.64 bcbs medicare advantage pos General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 2685.64 2685.64 bcbs medicare advantage ppo General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 2685.64 2685.64 bcbs medicare advantage pos General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 2685.64 2685.64 bcbs medicare advantage ppo General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 139.32 139.32 bcbs medicare advantage pos General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 139.32 139.32 bcbs medicare advantage ppo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 2685.64 2685.64 bcbs medicare advantage pos Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 2685.64 2685.64 bcbs medicare advantage ppo General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 2685.64 2685.64 bcbs medicare advantage pos General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 2685.64 2685.64 bcbs medicare advantage ppo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 2685.64 2685.64 bcbs medicare advantage pos Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 2685.64 2685.64 bcbs medicare advantage ppo Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 2685.64 2685.64 bcbs medicare advantage pos Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 2685.64 2685.64 bcbs medicare advantage ppo bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 6761.15 6761.15 bcbs medicare advantage pos bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 6761.15 6761.15 bcbs medicare advantage ppo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 912.58 912.58 bcbs medicare advantage pos respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 912.58 912.58 bcbs medicare advantage ppo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 20722.79 20722.79 bcbs medicare advantage pos "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 20722.79 20722.79 bcbs medicare advantage ppo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 4985.65 4985.65 bcbs medicare advantage pos transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 4985.65 4985.65 bcbs medicare advantage ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 99.29 99.29 champus insurance champus piperacillin/tazobactam cpt J2543 21270.9 21270.9 812.44 812.44 12102.08 12102.08 10085.07 10085.07 E 3117.11 3117.11 champus insurance champus "injection, pegfilgrastim 6mg" cpt J2505 21516.54 21516.54 6856.46 6856.46 40442.53 40442.53 33702.11 33702.11 O 10414.51 10414.51 champus insurance champus Tying of multiple internal hemorrhoid groups cpt 46946 17972.06 17972.06 2076.66 2076.66 15925.92 15925.92 13271.6 13271.6 O 2076.66 2076.66 champus insurance champus Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 100.27 100.27 champus insurance champus X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 161.43 161.43 champus insurance champus "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 25.57 25.57 champus insurance champus X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 161.43 161.43 champus insurance champus palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4311.72 4311.72 champus insurance champus seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 4709.98 4709.98 champus insurance champus Removal of tissue abnormalities of anus cpt 46922 2076.66 2076.66 2043.43 2043.43 17814.5 17814.5 14845.42 14845.42 O 2076.66 2076.66 champus insurance champus "injection, oritavancin" cpt J2407 3105.49 3105.49 210.36 210.36 7352.36 7352.36 6126.97 6126.97 O 3105.49 3105.49 champus insurance champus "injection, oritavancin" cpt J2407 3598.87 3598.87 3598.87 3598.87 8925.98 8925.98 7438.32 7438.32 E 3598.87 3598.87 champus insurance champus ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2683.82 2683.82 champus insurance champus "Needle biopsy of liver, accessed through the skin" cpt 47000 1559.48 1559.48 1215.96 1215.96 10715.04 10715.04 8929.2 8929.2 O 1215.96 1215.96 champus insurance champus Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 4282.09 4282.09 champus insurance champus Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 7.95 7.95 champus insurance champus diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 3915.43 3915.43 champus insurance champus diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 6966.42 6966.42 champus insurance champus Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 29.72 29.72 champus insurance champus ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 680.86 680.86 champus insurance champus Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.57 1965.57 champus insurance champus Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 224.22 224.22 champus insurance champus phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 champus insurance champus "other injury, poisoning and toxic effect diagnoses with mcc" ms-drg 922 13207.03 13207.03 8531.27 8531.27 34786.19 34786.19 28988.49 28988.49 I 13207.03 13207.03 champus insurance champus orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 197.85 197.85 champus insurance champus "octreotide inj, non-depot" cpt J2354 6865.24 6865.24 1357.6 1357.6 10984.32 10984.32 9153.6 9153.6 O 1444.99 1444.99 champus insurance champus o.r. procedures for obesity without cc/mcc ms-drg 621 17948.64 17948.64 9347.86 9347.86 51584.39 51584.39 42986.99 42986.99 I 9371.18 9371.18 champus insurance champus X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 champus insurance champus Biopsy of abdomen using an endoscope cpt 49321 7453.01 7453.01 4282.09 4282.09 31398.76 31398.76 26165.63 26165.63 O 7453.01 7453.01 champus insurance champus Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 161.43 161.43 champus insurance champus Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 champus insurance champus o.r. procedures for obesity with cc ms-drg 620 11977.51 11977.51 10950.84 10950.84 49613.87 49613.87 41344.89 41344.89 I 11977.51 11977.51 champus insurance champus inj naloxone hydrochloride cpt J2310 3917.15 3917.15 1917.44 1917.44 24768.65 24768.65 20640.54 20640.54 O 1917.44 1917.44 champus insurance champus Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 12.46 12.46 champus insurance champus "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 25.92 25.92 champus insurance champus "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 champus insurance champus Aspiration of abdominal cavity or cyst using an endoscope cpt 49322 4282.09 4282.09 4092 4092 30438.56 30438.56 25365.47 25365.47 O 4282.09 4282.09 champus insurance champus morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 4282.09 4282.09 champus insurance champus Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 4.4 4.4 champus insurance champus "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 222.96 222.96 champus insurance champus "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 32.11 32.11 champus insurance champus MRI scan of abdomen before and after contrast cpt 74183 338.27 338.27 335.57 335.57 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 champus insurance champus Homocysteine (amino acid) level cpt 83090 17.99 17.99 17.92 17.92 46.8 46.8 39 39 O 17.99 17.99 champus insurance champus morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 812.68 812.68 champus insurance champus Hydroxyindolacetic acid (product of metabolism) level cpt 83497 14.39 14.39 11.47 11.47 228.96 228.96 190.8 190.8 O 14.39 14.39 champus insurance champus "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 champus insurance champus Insertion of abdominal cavity catheter using an endoscope cpt 49324 4282.09 4282.09 3925.09 3925.09 21801.68 21801.68 18168.07 18168.07 O 4282.09 4282.09 champus insurance champus Thyroglobulin (thyroid related hormone) level cpt 84432 16.13 16.13 14.29 14.29 100.49 100.49 83.74 83.74 O 16.13 16.13 champus insurance champus MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 12.92 12.92 champus insurance champus inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 champus insurance champus "Repair of incisional or abdominal hernia, recurrent of secondary, not trapped" cpt 49565 4282.09 4282.09 4282.09 4282.09 24204.56 24204.56 20170.47 20170.47 O 4282.09 4282.09 champus insurance champus "Evaluation of heart rhythm monitor system implanted under skin with qualified health care professional analysis, review, and report" cpt 93291 101.06 101.06 20.37 20.37 137.38 137.38 114.48 114.48 O 20.37 20.37 champus insurance champus "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.57 1965.57 champus insurance champus CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 338.27 338.27 champus insurance champus "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 27.28 27.28 champus insurance champus inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 4282.09 4282.09 champus insurance champus cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 3522.68 3522.68 champus insurance champus "injection, mepolizumab, 1mg" cpt J2182 2982.57 2982.57 2982.57 2982.57 8542.16 8542.16 7118.47 7118.47 O 2982.57 2982.57 champus insurance champus "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 334.5 334.5 champus insurance champus Repair of hernia at navel patient age 5 years or older cpt 49585 2754.5 2754.5 2624.9 2624.9 19799.99 19799.99 16499.99 16499.99 O 2754.5 2754.5 champus insurance champus "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 champus insurance champus meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 4282.09 4282.09 champus insurance champus CT scan of abdomen and pelvis before and after contrast cpt 74178 338.27 338.27 332.86 332.86 4935.36 4935.36 4112.8 4112.8 E 338.27 338.27 champus insurance champus CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 206.45 206.45 champus insurance champus meperidine hydrochl /100 mg cpt J2175 4282.09 4282.09 1368.64 1368.64 13257.42 13257.42 11047.85 11047.85 E 4282.09 4282.09 champus insurance champus cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 5935.19 5935.19 champus insurance champus mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 7923.09 7923.09 champus insurance champus "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 107.9 107.9 champus insurance champus "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 517.64 517.64 197.85 197.85 1425.3 1425.3 1187.75 1187.75 E 197.85 197.85 champus insurance champus "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 426.62 426.62 champus insurance champus Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 99.29 99.29 champus insurance champus Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 8791.16 8791.16 champus insurance champus Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 champus insurance champus lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 7453.01 7453.01 champus insurance champus lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 465.08 465.08 champus insurance champus lidocaine injection cpt J2001 2164.03 2164.03 686.47 686.47 17322.78 17322.78 14435.65 14435.65 O 686.47 686.47 champus insurance champus "tendonitis, myositis and bursitis without mcc" ms-drg 558 5634.19 5634.19 2674.8 2674.8 15380.44 15380.44 12817.03 12817.03 I 3373.57 3373.57 champus insurance champus Abdominal procedure cpt 49999 696.23 696.23 696.23 696.23 19383.04 19383.04 16152.53 16152.53 O 696.23 696.23 champus insurance champus Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 champus insurance champus Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 2524.71 2524.71 champus insurance champus septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10026.87 10026.87 champus insurance champus "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 1215.96 1215.96 champus insurance champus Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 champus insurance champus CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 206.45 206.45 champus insurance champus "Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12013 732.06 732.06 214.42 214.42 5787.49 5787.49 4822.91 4822.91 E 214.42 214.42 champus insurance champus "Repair of wound (2.5 centimeters or less) of neck, hands, feet, and/or genitals" cpt 12041 506.01 506.01 506.01 506.01 1997.34 1997.34 1664.45 1664.45 E 506.01 506.01 champus insurance champus "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.06 9.06 champus insurance champus Injection for X-ray imaging of aorta above heart valve cpt 93567 2524.71 2524.71 2524.71 2524.71 22959.67 22959.67 19133.06 19133.06 O 2524.71 2524.71 champus insurance champus levofloxacin injection cpt J1956 4436.99 4436.99 1541.69 1541.69 17091.4 17091.4 14242.83 14242.83 O 2674.06 2674.06 champus insurance champus Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 326.12 326.12 champus insurance champus Evaluation of heart function using tilt table cpt 93660 430.19 430.19 286.66 286.66 1264.37 1264.37 1053.64 1053.64 O 430.19 430.19 champus insurance champus "Repair of wound (2.5 centimeters or less) of neck, hands, feet, and/or genitals" cpt 12041 1215.96 1215.96 1196.5 1196.5 3949.92 3949.92 3291.6 3291.6 O 1215.96 1215.96 champus insurance champus "Repair of wound (2.6 to 7.5 centimeters) of neck, hands, feet, and/or genitals" cpt 12042 2037.83 2037.83 1215.96 1215.96 3714.06 3714.06 3095.05 3095.05 O 1215.96 1215.96 champus insurance champus levofloxacin injection cpt J1956 2485.45 2485.45 941.32 941.32 14500.13 14500.13 12083.44 12083.44 E 941.32 941.32 champus insurance champus Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 682.29 682.29 champus insurance champus Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 2674.06 2674.06 champus insurance champus Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 206.45 206.45 champus insurance champus levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 180.31 180.31 champus insurance champus "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.58 11.58 champus insurance champus furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1409.82 1409.82 champus insurance champus Injection procedure for X-ray imaging of the bladder or during voiding cpt 51600 412.9 412.9 62.56 62.56 2807.77 2807.77 2339.81 2339.81 O 206.45 206.45 champus insurance champus viral illness without mcc ms-drg 866 5584.95 5584.95 2164.75 2164.75 24105.13 24105.13 20087.61 20087.61 I 4294.18 4294.18 champus insurance champus furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 5563.26 5563.26 champus insurance champus ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 3766.39 3766.39 champus insurance champus Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 206.45 206.45 champus insurance champus CT scan abdomen with contrast cpt 74160 161.43 161.43 161.43 161.43 2148.41 2148.41 1790.34 1790.34 E 161.43 161.43 champus insurance champus "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 96.59 96.59 champus insurance champus back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 8512.61 8512.61 champus insurance champus back and neck procedures except spinal fusion with cc ms-drg 519 36370.92 36370.92 10756.98 10756.98 60402.74 60402.74 50335.62 50335.62 I 11025.42 11025.42 champus insurance champus Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 champus insurance champus Diagnostic examination of the bladder and bladder canal (urethra) using an endoscope cpt 52000 2674.06 2674.06 1569.38 1569.38 18026.12 18026.12 15021.77 15021.77 O 2674.06 2674.06 champus insurance champus Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.14 15.14 champus insurance champus Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 99.29 99.29 champus insurance champus ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 268.55 268.55 champus insurance champus Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.25 16.25 champus insurance champus infliximab not biosimil 10mg cpt J1745 2621.84 2621.84 2621.84 2621.84 15293.02 15293.02 12744.18 12744.18 O 2621.84 2621.84 champus insurance champus hydrocortisone sodium succ i cpt J1720 4282.09 4282.09 2580.23 2580.23 7796.72 7796.72 6497.27 6497.27 E 4282.09 4282.09 champus insurance champus Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 champus insurance champus "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 3.94 3.94 champus insurance champus inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 7453.01 7453.01 champus insurance champus back and neck procedures except spinal fusion with mcc or disc device or neurostimulator ms-drg 518 14166.16 14166.16 14166.16 14166.16 99602.48 99602.48 83002.07 83002.07 I 14166.16 14166.16 champus insurance champus Ultrasound study of arteries and arterial grafts of one arm or limited cpt 93931 99.29 99.29 88.01 88.01 657.62 657.62 548.02 548.02 E 99.29 99.29 champus insurance champus Ultrasound study of arteries and arterial grafts of one arm or limited cpt 93931 431.57 431.57 97.7 97.7 657.62 657.62 548.02 548.02 O 99.29 99.29 champus insurance champus Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 206.45 206.45 champus insurance champus Insertion of catheter into urinary duct (ureter) using an endoscope through the bladder area cpt 52005 1569.38 1569.38 1500.24 1500.24 16097.6 16097.6 13414.67 13414.67 O 1569.38 1569.38 champus insurance champus "Measurement of substance using immunoassay technique, by radioimmunoassay" cpt 83519 18.48 18.48 16.37 16.37 226.42 226.42 188.68 188.68 O 18.48 18.48 champus insurance champus other musculoskeletal system and connective tissue o.r. procedures without cc/mcc ms-drg 517 9446.71 9446.71 4008.64 4008.64 36975.23 36975.23 30812.69 30812.69 I 9446.71 9446.71 champus insurance champus inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1965.57 1965.57 champus insurance champus Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 champus insurance champus "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 99.29 99.29 champus insurance champus Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 11080.96 11080.96 champus insurance champus Destruction of (less than 0.5 centimeters) growths of the bladder and bladder canal (urethra) using an endoscope cpt 52224 1569.38 1569.38 1544.27 1544.27 17268.6 17268.6 14390.5 14390.5 O 1569.38 1569.38 champus insurance champus Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 99.29 99.29 champus insurance champus "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 15.03 15.03 champus insurance champus inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 2524.71 2524.71 champus insurance champus inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 1952.13 1952.13 champus insurance champus Incision of the bladder canal (urethra) using an endoscope cpt 52276 1569.38 1569.38 1544.27 1544.27 17091.4 17091.4 14242.83 14242.83 O 1569.38 1569.38 champus insurance champus Dilation of bladder canal (urethra) using an endoscope cpt 52281 1569.38 1569.38 1569.38 1569.38 15026.72 15026.72 12522.27 12522.27 O 1569.38 1569.38 champus insurance champus Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 99.29 99.29 champus insurance champus other musculoskeletal system and connective tissue o.r. procedures with cc ms-drg 516 13074.37 13074.37 12081.3 12081.3 47397.76 47397.76 39498.13 39498.13 I 13074.37 13074.37 champus insurance champus "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 17.01 17.01 champus insurance champus "Ventilation assistance and management, hospital inpatient or observation, initial day" cpt 94002 2333.86 2333.86 1055.23 1055.23 9290.54 9290.54 7742.12 7742.12 E 2333.86 2333.86 champus insurance champus "Ventilation assistance and management, hospital inpatient or observation, initial day" cpt 94002 1466.26 1466.26 1199.26 1199.26 13744.27 13744.27 11453.56 11453.56 O 1427.41 1427.41 champus insurance champus Small bone graft harvest cpt 20900 10542.6 10542.6 10542.6 10542.6 101990.27 101990.27 84991.89 84991.89 O 10542.6 10542.6 champus insurance champus Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 4.77 4.77 champus insurance champus Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 224.22 224.22 champus insurance champus inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 champus insurance champus local excision and removal of internal fixation devices of hip and femur with cc/mcc ms-drg 498 11039.03 11039.03 11039.03 11039.03 75959.83 75959.83 63299.86 63299.86 I 11039.03 11039.03 champus insurance champus inj heparin sodium per 10 u cpt J1642 6841.37 6841.37 541.93 541.93 4972.12 4972.12 4143.43 4143.43 E 789.07 789.07 champus insurance champus "Removal of foreign body, stone, or stent from bladder canal (urethra) or bladder using an endoscope" cpt 52310 1569.38 1569.38 1569.38 1569.38 6452.41 6452.41 5377.01 5377.01 E 1569.38 1569.38 champus insurance champus Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 15.48 15.48 champus insurance champus "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 224.22 224.22 champus insurance champus Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 2674.06 2674.06 champus insurance champus haloperidol injection cpt J1630 711.92 711.92 360.62 360.62 5059.73 5059.73 4216.44 4216.44 E 360.62 360.62 champus insurance champus Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 268.55 268.55 champus insurance champus Measurement of substance using immunoassay technique cpt 83520 33.85 33.85 15.36 15.36 39.43 39.43 32.86 32.86 O 17.34 17.34 champus insurance champus glucagon hydrochloride/1 mg cpt J1610 1531.4 1531.4 468.43 468.43 3889.4 3889.4 3241.17 3241.17 E 468.43 468.43 champus insurance champus "Diagnostic examination of the bladder, bladder canal (urethra), and urinary duct (ureter) or kidney using an endoscope" cpt 52351 2674.06 2674.06 2674.06 2674.06 14430 14430 12025 12025 O 2674.06 2674.06 champus insurance champus "lower extremity and humerus procedures except hip, foot and femur without cc/mcc" ms-drg 494 33138.65 33138.65 7298.14 7298.14 52502.23 52502.23 43751.86 43751.86 I 9797.37 9797.37 champus insurance champus garamycin gentamicin inj cpt J1580 10542.6 10542.6 2021.39 2021.39 29695.73 29695.73 24746.44 24746.44 O 10542.6 10542.6 champus insurance champus Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 2683.82 2683.82 champus insurance champus inj ivig privigen 500 mg cpt J1459 3799.33 3799.33 2693.89 2693.89 11760.28 11760.28 9800.23 9800.23 O 2693.89 2693.89 champus insurance champus "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 champus insurance champus Removal or manipulation of stone in urinary duct (ureter) or kidney using an endoscope cpt 52352 4436.99 4436.99 2519.87 2519.87 23377.46 23377.46 19481.22 19481.22 O 2674.06 2674.06 champus insurance champus Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 357.24 357.24 champus insurance champus postoperative and post-traumatic infections without mcc ms-drg 863 15967.49 15967.49 2487.74 2487.74 15221.04 15221.04 12684.2 12684.2 I 2487.74 2487.74 champus insurance champus "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 11.48 11.48 champus insurance champus "Partial thickness skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children)" cpt 15120 11689.03 11689.03 2683.82 2683.82 19013.27 19013.27 15844.39 15844.39 O 2683.82 2683.82 champus insurance champus MRI scan of leg joint with contrast cpt 73722 603.12 603.12 603.12 603.12 2213.52 2213.52 1844.6 1844.6 O 603.12 603.12 champus insurance champus "Demonstration and/or evaluation of patient use of aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device" cpt 94664 2121.81 2121.81 216.25 216.25 2288.58 2288.58 1907.15 1907.15 E 612.63 612.63 champus insurance champus "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 166.39 166.39 champus insurance champus "lower extremity and humerus procedures except hip, foot and femur with cc" ms-drg 493 17098.05 17098.05 11409.73 11409.73 65822.2 65822.2 54851.83 54851.83 I 14057.92 14057.92 champus insurance champus Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 612.63 612.63 champus insurance champus "Grafting of patient soft tissue, harvested by direct excision" cpt 15769 7920.95 7920.95 7920.95 7920.95 65099.52 65099.52 54249.6 54249.6 O 7920.95 7920.95 champus insurance champus fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 2956.22 2956.22 champus insurance champus Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 champus insurance champus hip and femur procedures except major joint without cc/mcc ms-drg 482 18778.5 18778.5 9099.73 9099.73 55806.76 55806.76 46505.63 46505.63 I 9099.73 9099.73 champus insurance champus Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 champus insurance champus inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 13361.26 13361.26 champus insurance champus Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 3748.71 3748.71 champus insurance champus MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 716.79 716.79 champus insurance champus Dressing change and/or removal of burn tissue (less than 5% total body surface) cpt 16020 192.88 192.88 152.31 152.31 650.72 650.72 542.27 542.27 O 192.88 192.88 champus insurance champus CT scan of lower leg blood vessels with contrast cpt 73706 161.43 161.43 161.43 161.43 1985.59 1985.59 1654.66 1654.66 E 161.43 161.43 champus insurance champus Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 10624.49 10624.49 champus insurance champus inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 987.77 987.77 champus insurance champus CT scan leg with contrast injection cpt 73701 161.43 161.43 161.43 161.43 1658.69 1658.69 1382.24 1382.24 E 161.43 161.43 champus insurance champus Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.51 6.51 champus insurance champus "Removal of foreskin, patient older than 28 days of age" cpt 54161 1569.38 1569.38 1434.1 1434.1 15835.43 15835.43 13196.19 13196.19 O 1569.38 1569.38 champus insurance champus hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 13950.81 13950.81 champus insurance champus Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 805.22 805.22 champus insurance champus ertapenem injection cpt J1335 2076.66 2076.66 148.68 148.68 1092.52 1092.52 910.43 910.43 O 2076.66 2076.66 champus insurance champus CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 champus insurance champus Removal of testicle cpt 54520 2674.06 2674.06 2674.06 2674.06 19647.04 19647.04 16372.53 16372.53 O 2674.06 2674.06 champus insurance champus cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 15747.67 15747.67 champus insurance champus CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 99.29 99.29 champus insurance champus "Biopsy of breast accessed through the skin with stereotactic guidance, first lesion" cpt 19081 1215.96 1215.96 1215.96 1215.96 11913.47 11913.47 9927.89 9927.89 O 1215.96 1215.96 champus insurance champus "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 224.22 224.22 champus insurance champus ertapenem injection cpt J1335 891.9 891.9 639.12 639.12 8466.52 8466.52 7055.43 7055.43 E 674.98 674.98 champus insurance champus Repair of twisted testicle cpt 54600 2754.5 2754.5 2754.5 2754.5 18960.14 18960.14 15800.12 15800.12 O 2754.5 2754.5 champus insurance champus Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 545.11 545.11 champus insurance champus postoperative or post-traumatic infections with o.r. procedures with mcc ms-drg 856 65295.34 65295.34 23364.17 23364.17 104472.54 104472.54 87060.45 87060.45 I 25622.31 25622.31 champus insurance champus Repositioning and fixation of misplaced testicle cpt 54640 2754.5 2754.5 2754.5 2754.5 20760.92 20760.92 17300.77 17300.77 O 2754.5 2754.5 champus insurance champus Removal of sperm duct cpt 55250 1569.38 1569.38 1569.38 1569.38 16856.66 16856.66 14047.22 14047.22 O 1569.38 1569.38 champus insurance champus Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 325.54 325.54 champus insurance champus Incision or repair of sperm duct cpt 55400 2674.06 2674.06 2674.06 2674.06 33218.92 33218.92 27682.43 27682.43 O 2674.06 2674.06 champus insurance champus disorders of the biliary tract with mcc ms-drg 444 10366.72 10366.72 8535.61 8535.61 41391.48 41391.48 34492.9 34492.9 I 8700.71 8700.71 champus insurance champus diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 4311.72 4311.72 champus insurance champus Removal of spermatic cord venous dilation or tying of spermatic veins cpt 55530 2674.06 2674.06 2674.06 2674.06 21606.19 21606.19 18005.16 18005.16 O 2674.06 2674.06 champus insurance champus "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.7 70.7 champus insurance champus diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 541.93 541.93 champus insurance champus "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without cc/mcc" ms-drg 443 8609.76 8609.76 3148.67 3148.67 12770.82 12770.82 10642.35 10642.35 I 3148.67 3148.67 champus insurance champus Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 820.87 820.87 champus insurance champus "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 643.21 643.21 champus insurance champus "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with cc" ms-drg 442 6432.48 6432.48 2765.26 2765.26 15198.22 15198.22 12665.18 12665.18 I 2765.26 2765.26 champus insurance champus Spermatic cord procedure using an endoscope cpt 55559 7519.16 7519.16 4282.09 4282.09 32160.6 32160.6 26800.5 26800.5 O 4282.09 4282.09 champus insurance champus "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with mcc" ms-drg 441 14233.9 14233.9 9046.97 9046.97 48815.94 48815.94 40679.95 40679.95 I 14233.9 14233.9 champus insurance champus "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 987.77 987.77 champus insurance champus hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 4282.09 4282.09 champus insurance champus "Plastic repair of vagina and tissue separating vagina, rectum, and bladder" cpt 57260 7453.01 7453.01 7453.01 7453.01 52503.65 52503.65 43753.04 43753.04 O 7453.01 7453.01 champus insurance champus hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 913.96 913.96 champus insurance champus Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 12.86 12.86 champus insurance champus acetazolamid sodium injectio cpt J1120 197.85 197.85 197.85 197.85 1470.4 1470.4 1225.33 1225.33 E 197.85 197.85 champus insurance champus dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4282.09 4282.09 champus insurance champus "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 710.99 710.99 champus insurance champus Creation of sling around bladder canal (urethra) to control leakage cpt 57288 9490.45 9490.45 3784.07 3784.07 31149.61 31149.61 25958.01 25958.01 O 5618.54 5618.54 champus insurance champus infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 10706.37 10706.37 champus insurance champus Surgical vaginal defect repair using an endoscope cpt 57425 7453.01 7453.01 7453.01 7453.01 50987.53 50987.53 42489.61 42489.61 O 7453.01 7453.01 champus insurance champus "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.54 4.54 champus insurance champus dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 197.85 197.85 champus insurance champus "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 1275.2 1275.2 champus insurance champus methylprednisolone 80 mg inj cpt J1040 553.72 553.72 102.7 102.7 604.8 604.8 504 504 O 553.72 553.72 champus insurance champus methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 553.72 553.72 champus insurance champus disorders of pancreas except malignancy without cc/mcc ms-drg 440 13723.07 13723.07 3523.84 3523.84 16448.54 16448.54 13707.12 13707.12 I 3523.84 3523.84 champus insurance champus Removal of intra-uterine device (IUD) for pregnancy prevention cpt 58301 2260.96 2260.96 238.36 238.36 19397.1 19397.1 16164.25 16164.25 O 2260.96 2260.96 champus insurance champus Introduction of saline or X-ray contrast material for X-ray imaging of the uterus and tubes cpt 58340 206.45 206.45 206.45 206.45 3408.2 3408.2 2840.17 2840.17 O 206.45 206.45 champus insurance champus Examination of uterus with destruction of uterine lining using an endoscope cpt 58563 6142.86 6142.86 4033.08 4033.08 27275.76 27275.76 22729.8 22729.8 O 4033.08 4033.08 champus insurance champus disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 4802.1 4802.1 champus insurance champus Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4311.72 4311.72 champus insurance champus "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 930.84 930.84 champus insurance champus denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 2441.57 2441.57 champus insurance champus "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 70.7 70.7 champus insurance champus infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 29734.37 29734.37 champus insurance champus Zinc level cpt 84630 11.44 11.44 10.07 10.07 82.68 82.68 68.9 68.9 O 11.44 11.44 champus insurance champus "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 992.34 992.34 champus insurance champus "other injury, poisoning and toxic effect diagnoses without mcc" ms-drg 923 27632.25 27632.25 3062.32 3062.32 22082.47 22082.47 18402.06 18402.06 I 3062.32 3062.32 champus insurance champus Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 7453.01 7453.01 champus insurance champus "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 197.85 197.85 champus insurance champus "injection, dalbavancin" cpt J0875 4878.62 4878.62 2187.19 2187.19 11412.58 11412.58 9510.48 9510.48 E 4878.62 4878.62 champus insurance champus "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 16.84 16.84 champus insurance champus Removal of ovaries and/or tubes using an endoscope cpt 58661 5642.61 5642.61 3975.41 3975.41 24783.68 24783.68 20653.07 20653.07 O 4282.09 4282.09 champus insurance champus "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 2929.57 2929.57 champus insurance champus Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 3.95 3.95 champus insurance champus prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 2425.05 2425.05 champus insurance champus prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 541.93 541.93 champus insurance champus Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 4282.09 4282.09 champus insurance champus ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 4282.09 4282.09 champus insurance champus "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 607.46 607.46 champus insurance champus ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 champus insurance champus betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 1079.07 1079.07 champus insurance champus ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 162.77 162.77 champus insurance champus C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 20.9 20.9 champus insurance champus disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 10804.08 10804.08 champus insurance champus "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 906.43 906.43 champus insurance champus Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 118.36 118.36 champus insurance champus "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 70.7 70.7 champus insurance champus "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 677.23 677.23 champus insurance champus ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 197.85 197.85 champus insurance champus cefoxitin sodium injection cpt J0694 1952.13 1952.13 832.9 832.9 18152.78 18152.78 15127.32 15127.32 E 1952.13 1952.13 champus insurance champus Removal of ovarian or tubal pregnancy including removal of the ovary and/or tube using an endoscope cpt 59151 4282.09 4282.09 4282.09 4282.09 39845.57 39845.57 33204.64 33204.64 E 4282.09 4282.09 champus insurance champus "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1215.96 1215.96 champus insurance champus cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2719.16 2719.16 champus insurance champus "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4206.12 4206.12 champus insurance champus cefazolin sodium injection cpt J0690 9081.99 9081.99 1725.97 1725.97 18886.44 18886.44 15738.7 15738.7 E 2425.05 2425.05 champus insurance champus "Removal of breast growth, open procedure" cpt 19125 2683.82 2683.82 2683.82 2683.82 19864.31 19864.31 16553.59 16553.59 O 2683.82 2683.82 champus insurance champus leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 938.77 938.77 champus insurance champus Spinal tap for diagnosis cpt 62270 1258.34 1258.34 964.65 964.65 6589.96 6589.96 5491.63 5491.63 E 1000.66 1000.66 champus insurance champus Spinal tap with drainage of spinal fluid cpt 62272 6841.37 6841.37 1003.2 1003.2 4703.68 4703.68 3919.73 3919.73 E 1003.2 1003.2 champus insurance champus "Placement of breast localization devices accessed through the skin with mammographic guidance, first lesion" cpt 19281 2683.82 2683.82 194.62 194.62 23926.75 23926.75 19938.96 19938.96 O 2683.82 2683.82 champus insurance champus laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 8460.55 8460.55 champus insurance champus penicillin g benzathine inj cpt J0561 440.81 440.81 363.81 363.81 1358.89 1358.89 1132.41 1132.41 E 363.81 363.81 champus insurance champus "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1952.13 1952.13 champus insurance champus "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 1258.2 1258.2 champus insurance champus X-ray of upper spinal canal with radiological supervision and interpretation cpt 62302 941.39 941.39 691.17 691.17 7335.26 7335.26 6112.72 6112.72 O 941.39 941.39 champus insurance champus dicyclomine injection cpt J0500 718.51 718.51 233.2 233.2 3588.02 3588.02 2990.02 2990.02 E 233.2 233.2 champus insurance champus Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 10323.64 10323.64 champus insurance champus "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 99.29 99.29 champus insurance champus baclofen 10 mg injection cpt J0475 1289.69 1289.69 1289.69 1289.69 6057.1 6057.1 5047.58 5047.58 O 1289.69 1289.69 champus insurance champus Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 2441.57 2441.57 champus insurance champus "Placement of breast localization devices accessed through the skin with ultrasound guidance, first lesion" cpt 19285 4639.61 4639.61 2683.82 2683.82 30332.77 30332.77 25277.31 25277.31 O 2683.82 2683.82 champus insurance champus atropine sulfate injection cpt J0461 14120.9 14120.9 1106.07 1106.07 32990.4 32990.4 27492 27492 O 9547.8 9547.8 champus insurance champus Injection of substance into spinal canal of upper or middle back cpt 62320 553.72 553.72 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 553.72 553.72 champus insurance champus atropine sulfate injection cpt J0461 8792.66 8792.66 1934.02 1934.02 27478.69 27478.69 22898.91 22898.91 E 8792.66 8792.66 champus insurance champus azithromycin cpt J0456 1409.82 1409.82 147.92 147.92 9187.79 9187.79 7656.49 7656.49 O 1409.82 1409.82 champus insurance champus hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 4939.03 4939.03 champus insurance champus Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 759.68 759.68 champus insurance champus Electronic analysis reprogramming and refill of spinal canal drug infusion pump by physician cpt 62370 1289.69 1289.69 236.15 236.15 4731.84 4731.84 3943.2 3943.2 O 1289.69 1289.69 champus insurance champus Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 5299.29 5299.29 champus insurance champus "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 70.7 70.7 champus insurance champus hydralazine hcl injection cpt J0360 2136.63 2136.63 1934.02 1934.02 16012.49 16012.49 13343.74 13343.74 E 2136.63 2136.63 champus insurance champus "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 15.11 15.11 champus insurance champus succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 4282.09 4282.09 champus insurance champus Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 938.77 938.77 champus insurance champus Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 142.79 142.79 champus insurance champus laparoscopic cholecystectomy without c.d.e. with cc ms-drg 418 12197.9 12197.9 5638.44 5638.44 46278.29 46278.29 38565.24 38565.24 I 5638.44 5638.44 champus insurance champus Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4286.52 4286.52 champus insurance champus succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 3307.98 3307.98 champus insurance champus "Re-exploration of spine repair with release of lower spinal cord or nerves, single interspace" cpt 63042 10573.89 10573.89 5299.29 5299.29 30661.06 30661.06 25550.88 25550.88 O 5299.29 5299.29 champus insurance champus ampicillin sulbactam 1.5 gm cpt J0295 2069.31 2069.31 534.88 534.88 3702.38 3702.38 3085.32 3085.32 E 669.6 669.6 champus insurance champus ampicillin 500 mg inj cpt J0290 3073.87 3073.87 486.78 486.78 6558.29 6558.29 5465.24 5465.24 O 1524.42 1524.42 champus insurance champus adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 champus insurance champus laparoscopic cholecystectomy without c.d.e. with mcc ms-drg 417 13810.6 13810.6 10906.98 10906.98 46700.2 46700.2 38916.83 38916.83 I 10906.98 10906.98 champus insurance champus Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 2683.82 2683.82 champus insurance champus Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 7923.09 7923.09 champus insurance champus "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 70.7 70.7 champus insurance champus "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 5381.9 5381.9 champus insurance champus Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.8 5.8 champus insurance champus Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 8184.57 8184.57 champus insurance champus Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 7.55 7.55 champus insurance champus adrenalin epinephrine inject cpt J0171 2087.31 2087.31 439.13 439.13 3485.48 3485.48 2904.57 2904.57 E 439.13 439.13 champus insurance champus Partial removal of spine bone with release of spinal cord and/or nerves cpt 63048 5340.6 5340.6 5299.29 5299.29 30550.06 30550.06 25458.38 25458.38 O 5340.6 5340.6 champus insurance champus other digestive system diagnoses without cc/mcc ms-drg 395 6014.04 6014.04 3253.33 3253.33 12390.65 12390.65 10325.54 10325.54 I 4324.06 4324.06 champus insurance champus Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 8132.37 8132.37 champus insurance champus Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 5299.29 5299.29 champus insurance champus Radiological supervision and interpretation X-ray of hip joint cpt 73525 338.27 338.27 332.86 332.86 1232.57 1232.57 1027.14 1027.14 O 338.27 338.27 champus insurance champus acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 4282.09 4282.09 champus insurance champus Injection of anesthetic agent and/or steroid into other peripheral nerve or branch cpt 64450 686.5 686.5 553.72 553.72 1626.79 1626.79 1355.66 1355.66 E 553.72 553.72 champus insurance champus Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 champus insurance champus Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4639.61 4639.61 champus insurance champus Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 625.38 625.38 champus insurance champus acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 3209.36 3209.36 champus insurance champus chemotherapy without acute leukemia as secondary diagnosis with mcc ms-drg 846 17225.19 17225.19 7611.67 7611.67 47658.86 47658.86 39715.72 39715.72 I 17225.19 17225.19 champus insurance champus "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 99.29 99.29 97.3 97.3 727.58 727.58 606.32 606.32 E 99.29 99.29 champus insurance champus "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 4028.98 4028.98 champus insurance champus "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 577.69 577.69 champus insurance champus "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 1079.07 1079.07 champus insurance champus Injections of trigger points in 1 or 2 muscles cpt 20552 593.86 593.86 593.86 593.86 2179.02 2179.02 1815.85 1815.85 E 593.86 593.86 champus insurance champus drug test def 1-7 classes cpt G0480 1427.41 1427.41 961.2 961.2 5732.09 5732.09 4776.74 4776.74 O 1427.41 1427.41 champus insurance champus Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 2.38 2.38 champus insurance champus "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 409.88 409.88 champus insurance champus "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 99.29 99.29 champus insurance champus "Injections of upper or middle spine facet joint using imaging guidance, single level" cpt 64490 1063.31 1063.31 719.38 719.38 4559.56 4559.56 3799.63 3799.63 O 719.38 719.38 champus insurance champus drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 446.94 446.94 champus insurance champus "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 894 894 champus insurance champus hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 111.53 111.53 champus insurance champus "esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc" ms-drg 391 8351.98 8351.98 6959.33 6959.33 31444.44 31444.44 26203.7 26203.7 I 6959.33 6959.33 champus insurance champus hospital outpt clinic visit cpt G0463 2553.53 2553.53 1934.02 1934.02 23345.64 23345.64 19454.7 19454.7 E 1952.13 1952.13 champus insurance champus "prostate biopsy, any mthd" cpt G0416 3688.73 3688.73 696.23 696.23 5130.25 5130.25 4275.21 4275.21 O 696.23 696.23 champus insurance champus "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3089.67 3089.67 champus insurance champus gastrointestinal obstruction without cc/mcc ms-drg 390 4096.32 4096.32 2655.11 2655.11 15854.21 15854.21 13211.84 13211.84 I 2947.02 2947.02 champus insurance champus "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 726.33 726.33 champus insurance champus gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 4276.41 4276.41 champus insurance champus inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 6097.78 6097.78 champus insurance champus "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1079.07 1079.07 champus insurance champus MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 603.12 603.12 champus insurance champus "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 1079.07 1079.07 champus insurance champus Aspiration and/or injection of large joint or joint capsule cpt 20610 678.84 678.84 467.14 467.14 2107.97 2107.97 1756.64 1756.64 E 678.84 678.84 champus insurance champus hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6461 6461 champus insurance champus "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 946.96 946.96 champus insurance champus MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 618.63 618.63 champus insurance champus hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1965.57 1965.57 champus insurance champus "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 2.38 2.38 champus insurance champus Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 231.9 231.9 champus insurance champus "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 3.03 3.03 champus insurance champus ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70.7 70.7 champus insurance champus "Self-care or home management training, each 15 minutes" cpt 97535 680.1 680.1 137.83 137.83 2973.6 2973.6 2478 2478 O 680.1 680.1 champus insurance champus "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2136.63 2136.63 2034.73 2034.73 15002.65 15002.65 12502.21 12502.21 E 2136.63 2136.63 champus insurance champus gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 5140.13 5140.13 champus insurance champus "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 1079.07 1079.07 champus insurance champus elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 863.02 863.02 champus insurance champus Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.78 8.78 champus insurance champus "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 380.16 380.16 champus insurance champus "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 199.87 199.87 champus insurance champus gastrointestinal hemorrhage with mcc ms-drg 377 17273.54 17273.54 7149.07 7149.07 36153.05 36153.05 30127.54 30127.54 I 11346.04 11346.04 champus insurance champus "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 4.01 4.01 champus insurance champus "Release of nerve of arm or leg, open procedure" cpt 64708 1523.14 1523.14 1523.14 1523.14 20985.68 20985.68 17488.07 17488.07 O 1523.14 1523.14 champus insurance champus "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 490.2 490.2 champus insurance champus MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 8777.72 8777.72 champus insurance champus Removal of deep bone implant cpt 20680 5259.68 5259.68 1627.49 1627.49 19506.22 19506.22 16255.18 16255.18 O 1627.49 1627.49 champus insurance champus Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 1523.14 1523.14 champus insurance champus inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 830.58 830.58 champus insurance champus Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 9.5 9.5 champus insurance champus "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 10624.85 10624.85 champus insurance champus CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 champus insurance champus colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 676.71 676.71 champus insurance champus "Evaluation of occupational therapy, typically 30 minutes" cpt 97165 2088.08 2088.08 2088.08 2088.08 16433.63 16433.63 13694.69 13694.69 E 2088.08 2088.08 champus insurance champus Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 1523.14 1523.14 champus insurance champus "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 4.5 4.5 champus insurance champus colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 676.71 676.71 champus insurance champus "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 561.64 561.64 champus insurance champus major gastrointestinal disorders and peritoneal infections without cc/mcc ms-drg 373 4953.28 4953.28 2914.2 2914.2 19001.1 19001.1 15834.25 15834.25 I 2914.2 2914.2 champus insurance champus "Removal of foreign body, external eye, cornea" cpt 65220 197.85 197.85 197.85 197.85 1109.51 1109.51 924.59 924.59 E 197.85 197.85 champus insurance champus CT scan of arm cpt 73200 99.29 99.29 99.29 99.29 1366.13 1366.13 1138.44 1138.44 E 99.29 99.29 champus insurance champus Fragmented donor bone graft or placement of material to promote bone growth for spine surgery cpt 20930 10573.89 10573.89 5215.79 5215.79 74066.99 74066.99 61722.49 61722.49 O 10542.6 10542.6 champus insurance champus lymphoma and non-acute leukemia with cc ms-drg 841 24430.5 24430.5 10276.4 10276.4 22126.63 22126.63 18438.86 18438.86 I 12578.51 12578.51 champus insurance champus "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 1099.17 1099.17 champus insurance champus "Removal or relocation of corneal conjunctiva, with graft" cpt 65426 1714.35 1714.35 1714.35 1714.35 20257.37 20257.37 16881.14 16881.14 O 1714.35 1714.35 champus insurance champus "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 champus insurance champus psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 78.86 78.86 champus insurance champus "Removal of cataract with insertion of lens, complex" cpt 66982 3382.58 3382.58 1639 1639 16101.53 16101.53 13417.94 13417.94 O 3382.58 3382.58 champus insurance champus other digestive system o.r. procedures with mcc ms-drg 356 24337.34 24337.34 16073.72 16073.72 87729.18 87729.18 73107.65 73107.65 I 16073.72 16073.72 champus insurance champus Removal of embedded foreign body in eyelid cpt 67938 437.47 437.47 437.47 437.47 1050.64 1050.64 875.53 875.53 E 437.47 437.47 champus insurance champus "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 257.49 257.49 champus insurance champus Clotting factor VIII (VW factor) antigen cpt 85246 23.03 23.03 20.4 20.4 166.63 166.63 138.86 138.86 O 23.03 23.03 champus insurance champus admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 2010.24 2010.24 champus insurance champus "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 70.7 70.7 champus insurance champus hernia procedures except inguinal and femoral without cc/mcc ms-drg 355 9838.77 9838.77 8545.85 8545.85 63563.32 63563.32 52969.43 52969.43 I 9838.77 9838.77 champus insurance champus Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 3.65 3.65 champus insurance champus Supplies and materials provided by the physician beyond those usually included in the office visit or service cpt 99070 410.93 410.93 410.93 410.93 2964.3 2964.3 2470.25 2470.25 E 410.93 410.93 champus insurance champus Supplies and materials provided by the physician beyond those usually included in the office visit or service cpt 99070 1127.01 1127.01 1127.01 1127.01 8570 8570 7141.67 7141.67 O 1127.01 1127.01 champus insurance champus Physician educational services provided in a group setting cpt 99078 4282.09 4282.09 4282.09 4282.09 33766.63 33766.63 28138.86 28138.86 E 4282.09 4282.09 champus insurance champus Physician educational services provided in a group setting cpt 99078 2674.06 2674.06 2674.06 2674.06 24203.03 24203.03 20169.19 20169.19 O 2674.06 2674.06 champus insurance champus Structural donor bone graft for spine surgery cpt 20931 10583.91 10583.91 5215.79 5215.79 74613.46 74613.46 62177.88 62177.88 O 10583.91 10583.91 champus insurance champus Removal of foreign body from ear canal cpt 69200 197.85 197.85 180.72 180.72 1026.5 1026.5 855.42 855.42 E 197.85 197.85 champus insurance champus "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 8791.16 8791.16 champus insurance champus "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2524.71 2524.71 champus insurance champus Harvest of bone from same spine incision for graft cpt 20936 10573.89 10573.89 10359.91 10359.91 90858.1 90858.1 75715.08 75715.08 O 10542.6 10542.6 champus insurance champus "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 115.63 115.63 champus insurance champus perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 14120.9 14120.9 champus insurance champus perc drug-el cor stent sing cpt C9600 11328.88 11328.88 8777.72 8777.72 81384.32 81384.32 67820.27 67820.27 E 8791.16 8791.16 champus insurance champus "X-ray of bones of nose, minimum of 3 views" cpt 70160 70.7 70.7 23.05 23.05 333.26 333.26 277.72 277.72 O 70.7 70.7 champus insurance champus lymphoma and non-acute leukemia with mcc ms-drg 840 24876.86 24876.86 16212.54 16212.54 103181.56 103181.56 85984.63 85984.63 I 24876.86 24876.86 champus insurance champus "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 8791.16 8791.16 1723.62 1723.62 51580.72 51580.72 42983.93 42983.93 E 8791.16 8791.16 champus insurance champus "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 338.27 338.27 champus insurance champus CT scan head or brain before and after contrast cpt 70470 161.43 161.43 107.65 107.65 2755.15 2755.15 2295.96 2295.96 E 161.43 161.43 champus insurance champus "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 3211.39 3211.39 champus insurance champus anal and stomal procedures with mcc ms-drg 347 18519.1 18519.1 18519.1 18519.1 87634.51 87634.51 73028.76 73028.76 I 18519.1 18519.1 champus insurance champus "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2524.71 2524.71 champus insurance champus CT scan of cranial cavity cpt 70480 99.29 99.29 94.12 94.12 1366.13 1366.13 1138.44 1138.44 E 99.29 99.29 champus insurance champus "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 7453.01 7453.01 champus insurance champus "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 3748.71 3748.71 champus insurance champus Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 352.64 352.64 champus insurance champus "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 70.7 70.7 champus insurance champus CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 champus insurance champus "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 2524.71 2524.71 champus insurance champus "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 8791.16 8791.16 champus insurance champus CT scan of cranial cavity with contrast cpt 70481 168.39 168.39 161.43 161.43 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 champus insurance champus CT scan of face with contrast cpt 70487 161.43 161.43 93.52 93.52 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 champus insurance champus "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 10.22 10.22 champus insurance champus "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 3912 3912 champus insurance champus "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 8791.16 8791.16 champus insurance champus "catheter, ablation" cpt C1886 6142.86 6142.86 4006.52 4006.52 26466.79 26466.79 22055.66 22055.66 O 4033.08 4033.08 champus insurance champus CT scan of neck with contrast cpt 70491 161.43 161.43 112.47 112.47 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 champus insurance champus Closed treatment of broken nasal bone with stabilization cpt 21320 2320.38 2320.38 2320.38 2320.38 16237.06 16237.06 13530.88 13530.88 O 2320.38 2320.38 champus insurance champus embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 11449.31 11449.31 champus insurance champus "Emergency department visit, self limited or minor problem" cpt 99281 137.73 137.73 56.33 56.33 209.88 209.88 174.9 174.9 E 61.67 61.67 champus insurance champus embolization protect syst cpt C1884 11328.88 11328.88 6589.84 6589.84 72908.51 72908.51 60757.09 60757.09 E 8791.16 8791.16 champus insurance champus CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 408.55 408.55 champus insurance champus "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 2674.06 2674.06 champus insurance champus "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 113.36 113.36 champus insurance champus Open treatment of broken thumb at wrist cpt 26665 2425.05 2425.05 2425.05 2425.05 35263.28 35263.28 29386.07 29386.07 O 2425.05 2425.05 champus insurance champus "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 7176.4 7176.4 champus insurance champus "stent, coated/cov w/del sys" cpt C1874 13873.2 13873.2 8777.72 8777.72 83814.13 83814.13 69845.11 69845.11 E 8791.16 8791.16 champus insurance champus "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 champus insurance champus appendectomy without complicated principal diagnosis without cc/mcc ms-drg 343 9395.5 9395.5 5698.84 5698.84 36435.43 36435.43 30362.86 30362.86 I 6538.67 6538.67 champus insurance champus "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 champus insurance champus Fibrinogen (factor 1) activity measurement cpt 85384 51 51 8.65 8.65 102.52 102.52 85.43 85.43 O 9.76 9.76 champus insurance champus CT scan of neck before and after contrast cpt 70492 697.54 697.54 161.43 161.43 2148.41 2148.41 1790.34 1790.34 O 161.43 161.43 champus insurance champus CT scan of blood vessel of head with contrast cpt 70496 306.42 306.42 159.8 159.8 1985.59 1985.59 1654.66 1654.66 E 161.43 161.43 champus insurance champus "ocular imp, aqueous drain de" cpt C1783 3382.58 3382.58 3382.58 3382.58 28467.73 28467.73 23723.11 23723.11 O 3382.58 3382.58 champus insurance champus mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 4282.09 4282.09 champus insurance champus joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 5299.29 5299.29 champus insurance champus appendectomy without complicated principal diagnosis with cc ms-drg 342 8397.82 8397.82 6592.95 6592.95 33691.25 33691.25 28076.04 28076.04 I 8397.82 8397.82 champus insurance champus CT scan of neck blood vessels with contrast cpt 70498 408.55 408.55 168.41 168.41 1985.59 1985.59 1654.66 1654.66 E 408.55 408.55 champus insurance champus guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 2524.71 2524.71 champus insurance champus guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 8791.16 8791.16 champus insurance champus "graft, vascular" cpt C1768 7453.01 7453.01 3902.07 3902.07 25441.12 25441.12 21200.93 21200.93 O 7453.01 7453.01 champus insurance champus "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 champus insurance champus "conn tiss, non-human" cpt C1763 10542.6 10542.6 9490.45 9490.45 54305.62 54305.62 45254.68 45254.68 O 10542.6 10542.6 champus insurance champus Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 19.05 19.05 champus insurance champus "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 541.93 541.93 champus insurance champus "conn tiss, human(inc fascia)" cpt C1762 5711.87 5711.87 5711.87 5711.87 73976.5 73976.5 61647.08 61647.08 O 5711.87 5711.87 champus insurance champus "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 8777.72 8777.72 champus insurance champus MRI scan brain cpt 70551 1815.29 1815.29 124.83 124.83 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 champus insurance champus "cath, intra echocardiography" cpt C1759 14120.9 14120.9 8704.03 8704.03 94032.49 94032.49 78360.41 78360.41 O 14120.9 14120.9 champus insurance champus "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 609.71 609.71 champus insurance champus "cath, intra echocardiography" cpt C1759 14000.33 14000.33 8792.66 8792.66 93375.96 93375.96 77813.3 77813.3 E 8792.66 8792.66 champus insurance champus appendectomy without complicated principal diagnosis with mcc ms-drg 341 14495.62 14495.62 9375.78 9375.78 41189.74 41189.74 34324.78 34324.78 I 9375.78 9375.78 champus insurance champus "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 2674.06 2674.06 champus insurance champus "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 10.15 10.15 champus insurance champus "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 2333.86 2333.86 2333.86 2333.86 14420.36 14420.36 12016.97 12016.97 E 2333.86 2333.86 champus insurance champus "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 champus insurance champus "Closed treatment of jaw temporomandibular joint (TMJ) dislocation, uncomplicated" cpt 21480 592.32 592.32 388.88 388.88 2606.84 2606.84 2172.37 2172.37 E 388.88 388.88 champus insurance champus "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 787.11 787.11 champus insurance champus appendectomy with complicated principal diagnosis with cc ms-drg 339 10970.51 10970.51 8877.02 8877.02 60592.91 60592.91 50494.09 50494.09 I 8877.02 8877.02 champus insurance champus MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 champus insurance champus "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 11449.31 11449.31 champus insurance champus peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 9763.35 9763.35 champus insurance champus Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 1284.15 1284.15 champus insurance champus "Preventive medicine counseling, approximately 15 minutes" cpt 99401 24.64 24.64 24.64 24.64 178.08 178.08 148.4 148.4 O 24.64 24.64 champus insurance champus Anesthesia procedure cpt 1999 4282.09 4282.09 4282.09 4282.09 33766.63 33766.63 28138.86 28138.86 E 4282.09 4282.09 champus insurance champus Anesthesia procedure cpt 1999 2674.06 2674.06 2674.06 2674.06 23709.52 23709.52 19757.93 19757.93 O 2674.06 2674.06 champus insurance champus "cath, translumin non-laser" cpt C1725 13873.2 13873.2 6589.84 6589.84 75620.26 75620.26 63016.88 63016.88 E 8791.16 8791.16 champus insurance champus Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 champus insurance champus Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 338.27 338.27 champus insurance champus "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 70.7 70.7 champus insurance champus "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.71 2.71 champus insurance champus major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 9891.43 9891.43 champus insurance champus "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 5299.29 5299.29 champus insurance champus "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 champus insurance champus Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 1569.38 1569.38 champus insurance champus "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 70.7 70.7 champus insurance champus "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 338.27 338.27 champus insurance champus Injection of substance into spinal canal of lower back or sacrum cpt 62322 1477.69 1477.69 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 553.72 553.72 champus insurance champus major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 15399.07 15399.07 champus insurance champus Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 553.72 553.72 champus insurance champus "gad-base mr contrast nos,1ml" cpt A9579 1952.13 1952.13 1005.31 1005.31 14304.31 14304.31 11920.26 11920.26 E 1382.41 1382.41 champus insurance champus "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 17.21 17.21 champus insurance champus f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 champus insurance champus "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 996.24 996.24 champus insurance champus Drainage of multiple abscess cpt 10061 480.9 480.9 454.66 454.66 1173.38 1173.38 977.82 977.82 E 480.9 480.9 champus insurance champus tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 326.12 326.12 champus insurance champus "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 1791.13 1791.13 champus insurance champus "Fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex" cpt 22551 10542.6 10542.6 10359.91 10359.91 56256.43 56256.43 46880.36 46880.36 O 10542.6 10542.6 champus insurance champus tc99m maa cpt A9540 1952.13 1952.13 1943.08 1943.08 13059.28 13059.28 10882.73 10882.73 E 1952.13 1952.13 champus insurance champus "Fusion of spine bones with removal of disc in upper spinal column below second vertebra of neck , anterior approach" cpt 22552 10542.6 10542.6 10542.6 10542.6 71210.34 71210.34 59341.95 59341.95 O 10542.6 10542.6 champus insurance champus tc99m pentetate cpt A9539 421.27 421.27 260.45 260.45 1775.23 1775.23 1479.36 1479.36 O 418.12 418.12 champus insurance champus Red blood cell sickling measurement cpt 85660 5.53 5.53 4.9 4.9 39.17 39.17 32.64 32.64 O 5.53 5.53 champus insurance champus Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 805.22 805.22 champus insurance champus "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 755.46 755.46 champus insurance champus "stomach, esophageal and duodenal procedures without cc/mcc" ms-drg 328 13958.64 13958.64 5175.14 5175.14 49664.04 49664.04 41386.7 41386.7 I 10222.4 10222.4 champus insurance champus MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 champus insurance champus "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 6.86 6.86 champus insurance champus tc99m pyrophosphate cpt A9538 326.12 326.12 320.9 320.9 2718.01 2718.01 2265.01 2265.01 O 326.12 326.12 champus insurance champus tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 467.77 467.77 champus insurance champus "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 118.72 118.72 champus insurance champus "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 70.7 70.7 champus insurance champus tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 734.67 734.67 champus insurance champus CT scan pelvis cpt 72192 99.29 99.29 76.69 76.69 1367.4 1367.4 1139.5 1139.5 E 99.29 99.29 champus insurance champus tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 champus insurance champus "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.03 6.03 champus insurance champus extensive o.r. procedures unrelated to principal diagnosis without cc/mcc ms-drg 983 10428.98 10428.98 8044.15 8044.15 43105.16 43105.16 35920.97 35920.97 I 8044.15 8044.15 champus insurance champus "stomach, esophageal and duodenal procedures with mcc" ms-drg 326 288925.38 288925.38 28518.81 28518.81 166466.87 166466.87 138722.39 138722.39 I 30301.35 30301.35 champus insurance champus MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 champus insurance champus tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.57 1965.57 champus insurance champus extensive o.r. procedures unrelated to principal diagnosis with cc ms-drg 982 14004.61 14004.61 2771.51 2771.51 62525.57 62525.57 52104.64 52104.64 I 2771.51 2771.51 champus insurance champus "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.7 70.7 champus insurance champus other circulatory system diagnoses with cc ms-drg 315 6368.18 6368.18 6098.97 6098.97 18163.28 18163.28 15136.07 15136.07 I 6098.97 6098.97 champus insurance champus CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 99.29 99.29 champus insurance champus "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 521.99 521.99 champus insurance champus Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.2 5.2 champus insurance champus CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 253.92 253.92 champus insurance champus "Fusion of lower spine bones, posterior or posterolateral approach" cpt 22612 10625.2 10625.2 71.67 71.67 98531.21 98531.21 82109.34 82109.34 O 10542.6 10542.6 champus insurance champus contact layer >16<= 48 sq in cpt A6207 102.7 102.7 28.09 28.09 1424.02 1424.02 1186.68 1186.68 O 102.7 102.7 champus insurance champus alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 283.05 283.05 champus insurance champus MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 champus insurance champus surgical supplies cpt A4649 9907.54 9907.54 2386.25 2386.25 23508.36 23508.36 19590.3 19590.3 O 5299.29 5299.29 champus insurance champus implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 2683.82 2683.82 champus insurance champus MRI scan of lower spinal canal before and after contrast cpt 72158 338.27 338.27 218.02 218.02 4123.82 4123.82 3436.52 3436.52 E 338.27 338.27 champus insurance champus tubing (oxygen) per foot cpt A4616 475.24 475.24 475.24 475.24 5870.3 5870.3 4891.92 4891.92 O 475.24 475.24 champus insurance champus Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 12.14 12.14 champus insurance champus "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 99.29 99.29 champus insurance champus slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 2425.05 2425.05 champus insurance champus chest pain ms-drg 313 5722.44 5722.44 3212.87 3212.87 19324.42 19324.42 16103.68 16103.68 I 3938.65 3938.65 champus insurance champus als 2 cpt A0433 751.18 751.18 634.19 634.19 1819.21 1819.21 1516.01 1516.01 O 751.18 751.18 champus insurance champus bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 386.48 386.48 champus insurance champus bls cpt A0428 911.16 911.16 251.75 251.75 819.6 819.6 683 683 O 911.16 911.16 champus insurance champus bls cpt A0428 911.16 911.16 251.75 251.75 819.6 819.6 683 683 O 629.22 629.22 champus insurance champus "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 10542.6 10542.6 champus insurance champus MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 champus insurance champus Quantitation of therapeutic drug cpt 80299 18.72 18.72 5.39 5.39 36.89 36.89 30.74 30.74 O 18.72 18.72 champus insurance champus als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 436.56 436.56 champus insurance champus CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 champus insurance champus als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 950.89 950.89 champus insurance champus ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 629.22 629.22 champus insurance champus MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 2923.72 2923.72 champus insurance champus ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 428.94 428.94 champus insurance champus CT scan pelvis with contrast cpt 72193 989.18 989.18 161.43 161.43 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 champus insurance champus Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 62.54 62.54 champus insurance champus "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.31 4.31 champus insurance champus CT scan chest with contrast cpt 71260 917.69 917.69 147.45 147.45 1913.09 1913.09 1594.24 1594.24 E 917.69 917.69 champus insurance champus MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 10542.6 10542.6 champus insurance champus CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 champus insurance champus CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 champus insurance champus cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 3295.73 3295.73 champus insurance champus "Insertion of anterior spinal instrumentation for spinal stabilization, 2 to 3 vertebral segments" cpt 22845 10542.6 10542.6 10359.91 10359.91 56691.74 56691.74 47243.12 47243.12 O 10542.6 10542.6 champus insurance champus "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.8 7.8 champus insurance champus CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 338.27 338.27 champus insurance champus "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 99.29 99.29 champus insurance champus MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 champus insurance champus "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 232.5 232.5 champus insurance champus Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 511.19 511.19 90.7 90.7 817.9 817.9 681.58 681.58 E 99.29 99.29 champus insurance champus "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.5 6.5 champus insurance champus Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 99.29 99.29 champus insurance champus Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.6 13.6 champus insurance champus Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.2 5.2 champus insurance champus Partial removal of bone with release of spinal cord or spinal nerves in upper or lower spine cpt 63035 5299.29 5299.29 5299.29 5299.29 41623.6 41623.6 34686.33 34686.33 O 5299.29 5299.29 champus insurance champus MRI scan of upper spinal canal cpt 72141 473.49 473.49 206.45 206.45 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 champus insurance champus Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 99.29 99.29 champus insurance champus CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 161.43 161.43 champus insurance champus "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.87 16.87 champus insurance champus seizures with mcc ms-drg 100 10932.38 10932.38 5168.61 5168.61 34160.78 34160.78 28467.32 28467.32 I 5168.61 5168.61 champus insurance champus "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 234.68 234.68 14.94 14.94 274.75 274.75 228.96 228.96 E 234.68 234.68 champus insurance champus hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 3377.11 3377.11 champus insurance champus Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 83.77 83.77 champus insurance champus CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 champus insurance champus "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 18.47 18.47 champus insurance champus CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 champus insurance champus other antepartum diagnoses without o.r. procedures without cc/mcc ms-drg 833 4609.85 4609.85 1574.02 1574.02 9601.67 9601.67 8001.39 8001.39 I 2030 2030 champus insurance champus Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 107.27 107.27 champus insurance champus CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 99.29 99.29 champus insurance champus Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.26 2.26 champus insurance champus peripheral vascular disorders without cc/mcc ms-drg 301 5270.88 5270.88 3333.6 3333.6 20288.41 20288.41 16907.01 16907.01 I 3764.88 3764.88 champus insurance champus "Drainage of tailbone cyst, uncomplicated" cpt 10080 738.25 738.25 738.25 738.25 1121.8 1121.8 934.83 934.83 E 738.25 738.25 champus insurance champus Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 26.98 26.98 champus insurance champus peripheral vascular disorders with mcc ms-drg 299 9368.28 9368.28 4924.74 4924.74 37040.12 37040.12 30866.77 30866.77 I 4924.74 4924.74 champus insurance champus Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.65 88.65 champus insurance champus Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 37.84 37.84 champus insurance champus "Removal of 1 or more breast growth, open procedure" cpt 19120 3225.81 3225.81 2571.39 2571.39 17570.48 17570.48 14642.07 14642.07 O 2683.82 2683.82 champus insurance champus CT scan of upper spine with contrast cpt 72126 338.27 338.27 338.27 338.27 1857.71 1857.71 1548.09 1548.09 O 338.27 338.27 champus insurance champus Shaving of shoulder bone using an endoscope cpt 29826 12067.91 12067.91 2425.05 2425.05 31991.54 31991.54 26659.62 26659.62 O 2425.05 2425.05 champus insurance champus "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.47 18.47 champus insurance champus "Measurement of complement (immune system proteins), antigen," cpt 86160 12.05 12.05 10.67 10.67 54.7 54.7 45.58 45.58 O 12.05 12.05 champus insurance champus Removal of one knee cartilage using an endoscope cpt 29881 7460.54 7460.54 2274.34 2274.34 20616.25 20616.25 17180.21 17180.21 O 2425.05 2425.05 champus insurance champus "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 70.7 70.7 champus insurance champus CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 champus insurance champus heart failure and shock without cc/mcc ms-drg 293 9035.93 9035.93 2941.69 2941.69 15739.96 15739.96 13116.63 13116.63 I 2941.69 2941.69 champus insurance champus "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 champus insurance champus "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 696.23 696.23 champus insurance champus Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.2 8.2 champus insurance champus Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 13.69 13.69 champus insurance champus Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 8.72 8.72 champus insurance champus CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 99.29 99.29 champus insurance champus "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 99.29 99.29 champus insurance champus Insertion of device into intervertebral disc space of spine and fusion of vertebrae cpt 22853 10542.6 10542.6 10542.6 10542.6 55458.7 55458.7 46215.58 46215.58 O 10542.6 10542.6 champus insurance champus Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 676.71 676.71 champus insurance champus Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 13 13 champus insurance champus "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 99.29 99.29 champus insurance champus X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 99.29 99.29 champus insurance champus "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.44 13.44 champus insurance champus "Insertion of artificial upper spine disc, anterior approach" cpt 22856 14208.92 14208.92 14208.92 14208.92 67805.96 67805.96 56504.97 56504.97 O 14208.92 14208.92 champus insurance champus Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 champus insurance champus "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.44 13.44 champus insurance champus Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 1237.74 1237.74 champus insurance champus heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 6706.49 6706.49 champus insurance champus "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 99.29 99.29 champus insurance champus other antepartum diagnoses without o.r. procedures with cc ms-drg 832 7684.4 7684.4 1960.72 1960.72 12643.03 12643.03 10535.86 10535.86 I 1960.72 1960.72 champus insurance champus "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.6 10.6 champus insurance champus "X-ray of spine, entire middle and lower spine, 1 view" cpt 72081 81.3 81.3 23.65 23.65 230.23 230.23 191.86 191.86 O 70.7 70.7 champus insurance champus Partial removal of collar bone cpt 23120 5299.29 5299.29 5299.29 5299.29 31887.79 31887.79 26573.16 26573.16 O 5299.29 5299.29 champus insurance champus "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 271.34 271.34 champus insurance champus "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 238.4 238.4 champus insurance champus "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.49 8.49 champus insurance champus "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 18 18 champus insurance champus Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 6.06 6.06 champus insurance champus Screening test for antibody to noninfectious agent cpt 86255 12.1 12.1 8.25 8.25 94.8 94.8 79 79 O 12.1 12.1 champus insurance champus Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 941.39 941.39 champus insurance champus "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 6355.08 6355.08 champus insurance champus Open treatment of collar bone broken cpt 23515 5299.29 5299.29 5299.29 5299.29 33572.42 33572.42 27977.02 27977.02 O 5299.29 5299.29 champus insurance champus Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 19.78 19.78 champus insurance champus "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 5315.78 5315.78 champus insurance champus "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 18.66 18.66 champus insurance champus "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.9 20.9 champus insurance champus "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 20.9 20.9 champus insurance champus Open treatment of collar bone and shoulder joint dislocation cpt 23550 5299.29 5299.29 5299.29 5299.29 47480.96 47480.96 39567.47 39567.47 O 5299.29 5299.29 champus insurance champus other antepartum diagnoses without o.r. procedures with mcc ms-drg 831 8473.81 8473.81 3236.69 3236.69 13886.92 13886.92 11572.43 11572.43 I 4249.78 4249.78 champus insurance champus lymphoma and leukemia with major o.r. procedures without cc/mcc ms-drg 822 18012.77 18012.77 8024.86 8024.86 29988.86 29988.86 24990.72 24990.72 I 8024.86 8024.86 champus insurance champus "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 23.22 23.22 champus insurance champus "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 13.6 13.6 champus insurance champus Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 142.04 142.04 champus insurance champus Analysis for detection of tumor marker cpt 86316 22.06 22.06 18.51 18.51 133.56 133.56 111.3 111.3 O 22.06 22.06 champus insurance champus Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 3.29 3.29 champus insurance champus "Removal of foreign body from tissue, accessed beneath the skin, simple" cpt 10120 635.65 635.65 381.98 381.98 1477.88 1477.88 1231.57 1231.57 E 381.98 381.98 champus insurance champus "Digoxin level, total" cpt 80162 153.36 153.36 11.81 11.81 175.27 175.27 146.06 146.06 E 153.36 153.36 champus insurance champus Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.43 22.43 champus insurance champus other antepartum diagnoses with o.r. procedures without cc/mcc ms-drg 819 9322.89 9322.89 5314.57 5314.57 36119.1 36119.1 30099.25 30099.25 I 5314.57 5314.57 champus insurance champus Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 135.92 135.92 champus insurance champus Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.5 6.5 champus insurance champus "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.47 29.47 champus insurance champus Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 47.83 47.83 champus insurance champus Closed treatment of shoulder dislocation with manipulation cpt 23650 699.2 699.2 502.67 502.67 3187.81 3187.81 2656.51 2656.51 E 502.67 502.67 champus insurance champus Closed treatment of shoulder dislocation with manipulation under anesthesia cpt 23655 1200.71 1200.71 1181.5 1181.5 3146.57 3146.57 2622.14 2622.14 E 1200.71 1200.71 champus insurance champus "Aspiration of abscess, blood accumulation, blister, or cyst" cpt 10160 480.9 480.9 480.9 480.9 1074.16 1074.16 895.13 895.13 E 480.9 480.9 champus insurance champus other vascular procedures without cc/mcc ms-drg 254 13485.52 13485.52 10936.61 10936.61 37141.75 37141.75 30951.46 30951.46 I 10936.61 10936.61 champus insurance champus percutaneous cardiovascular procedures without coronary artery stent without mcc ms-drg 251 12258.03 12258.03 7183.91 7183.91 79584.41 79584.41 66320.34 66320.34 I 12258.03 12258.03 champus insurance champus Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 11.59 11.59 champus insurance champus Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 5.43 5.43 champus insurance champus Shoulder procedure cpt 23929 2425.05 2425.05 2425.05 2425.05 26671.7 26671.7 22226.42 22226.42 O 2425.05 2425.05 champus insurance champus Manipulation of elbow under anesthesia cpt 24300 1904.67 1904.67 1200.71 1200.71 21085.42 21085.42 17571.18 17571.18 O 1200.71 1200.71 champus insurance champus Reinsertion of torn biceps or triceps tendon at elbow cpt 24342 5299.29 5299.29 5299.29 5299.29 36634.48 36634.48 30528.73 30528.73 O 5299.29 5299.29 champus insurance champus Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.17 6.17 champus insurance champus "Removal of foreign material from skin, tissue, muscle, and bone at open fracture and/or dislocation" cpt 11012 2054.26 2054.26 2054.26 2054.26 23211.38 23211.38 19342.82 19342.82 O 2054.26 2054.26 champus insurance champus red blood cell disorders without mcc ms-drg 812 8135.51 8135.51 3725.55 3725.55 22117.79 22117.79 18431.49 18431.49 I 4194.25 4194.25 champus insurance champus percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 14509.1 14509.1 champus insurance champus Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.92 6.92 champus insurance champus Closed treatment of a break of the mid portion of upper arm bone with manipulation cpt 24505 1200.71 1200.71 1200.71 1200.71 2667.18 2667.18 2222.65 2222.65 E 1200.71 1200.71 champus insurance champus percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 19800.43 19800.43 champus insurance champus "Open treatment of broken upper arm bone, mid-portion" cpt 24515 10542.6 10542.6 9716.73 9716.73 43848.08 43848.08 36540.07 36540.07 O 10542.6 10542.6 champus insurance champus Open treatment of the forearm bone on the small finger side of the forearm (Ulna bone) in the elbow region cpt 24685 5299.29 5299.29 5214.5 5214.5 41198.6 41198.6 34332.17 34332.17 O 5299.29 5299.29 champus insurance champus Syphilis detection test cpt 86592 4.77 4.77 2.99 2.99 132.29 132.29 110.24 110.24 E 4.77 4.77 champus insurance champus Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation cpt 25605 1200.71 1200.71 1162.07 1162.07 3895.34 3895.34 3246.12 3246.12 E 1200.71 1200.71 champus insurance champus coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 36449.33 36449.33 champus insurance champus poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 3341.91 3341.91 champus insurance champus Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 4.29 4.29 champus insurance champus Open treatment of broken of lower forearm bone or growth plate separation with insertion of hardware cpt 25607 16572.45 16572.45 4897.01 4897.01 36409.4 36409.4 30341.17 30341.17 O 5299.29 5299.29 champus insurance champus red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 7750.37 7750.37 champus insurance champus Nuclear medicine study with CT imaging whole body cpt 78816 2822.36 2822.36 1257.95 1257.95 8147.16 8147.16 6789.3 6789.3 O 1278.4 1278.4 champus insurance champus coronary bypass with ptca without mcc ms-drg 232 40869.47 40869.47 34390.85 34390.85 214749.47 214749.47 178957.89 178957.89 I 40869.47 40869.47 champus insurance champus Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 champus insurance champus Open treatment of broken of lower forearm or growth plate separation with insertion of hardware of 2 fragments cpt 25608 7889.33 7889.33 4927.02 4927.02 34718.63 34718.63 28932.19 28932.19 O 5299.29 5299.29 champus insurance champus Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 17.1 17.1 champus insurance champus Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 champus insurance champus Analysis for antibody to Cytomegalovirus (CMV) cpt 86644 23.13 23.13 12.8 12.8 85.22 85.22 71.02 71.02 O 14.45 14.45 champus insurance champus Analysis for antibody (IgM) to Cytomegalovirus (CMV) cpt 86645 21.06 21.06 14.99 14.99 77.59 77.59 64.66 64.66 O 16.92 16.92 champus insurance champus "Nuclear medicine study of kidney with assessment of blood flow and function, with or without drugs, multiple studies" cpt 78709 418.12 418.12 260.45 260.45 1436.09 1436.09 1196.74 1196.74 O 418.12 418.12 champus insurance champus "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 13.24 13.24 champus insurance champus "Drainage of finger abscess, uncomplicated" cpt 26010 352.64 352.64 229.65 229.65 1309.74 1309.74 1091.45 1091.45 E 352.64 352.64 champus insurance champus "Nuclear medicine study of heart wall motion at rest or stress with evaluation of blood ejection from heart, single study, gated equilibrium" cpt 78472 326.12 326.12 320.9 320.9 2477.86 2477.86 2064.88 2064.88 O 326.12 326.12 champus insurance champus respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 31797.23 31797.23 champus insurance champus IgE (immune system protein) level cpt 82785 36.9 36.9 11.05 11.05 75.05 75.05 62.54 62.54 O 16.53 16.53 champus insurance champus "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 19.43 19.43 champus insurance champus respiratory signs and symptoms ms-drg 204 5762.49 5762.49 3725.66 3725.66 11897.69 11897.69 9914.74 9914.74 I 4036.69 4036.69 champus insurance champus Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1127.01 1127.01 champus insurance champus vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 2859.8 2859.8 champus insurance champus bronchitis and asthma without cc/mcc ms-drg 203 5079.97 5079.97 2129.55 2129.55 10737.54 10737.54 8947.95 8947.95 I 3230.8 3230.8 champus insurance champus vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 3354.09 3354.09 champus insurance champus transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5189.12 5189.12 champus insurance champus bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 3549.64 3549.64 champus insurance champus Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 27.03 27.03 champus insurance champus pneumothorax without cc/mcc ms-drg 201 5301.15 5301.15 2927.64 2927.64 20972.84 20972.84 17477.37 17477.37 I 2927.64 2927.64 champus insurance champus pneumothorax with cc ms-drg 200 22906.66 22906.66 4418.11 4418.11 25021.14 25021.14 20850.95 20850.95 I 5017.66 5017.66 champus insurance champus Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 10.78 10.78 champus insurance champus simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 3186.06 3186.06 champus insurance champus Closed treatment of fracture of bone of hand with manipulation cpt 26605 502.67 502.67 415.61 415.61 2849.98 2849.98 2374.98 2374.98 E 502.67 502.67 champus insurance champus Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.73 6.73 champus insurance champus other o.r. procedures of the blood and blood forming organs with mcc ms-drg 802 99018.13 99018.13 99018.13 99018.13 112642.81 112642.81 93869.01 93869.01 I 99018.13 99018.13 champus insurance champus simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 4488.94 4488.94 champus insurance champus headaches without mcc ms-drg 103 5109.57 5109.57 3174.19 3174.19 17526.64 17526.64 14605.53 14605.53 I 4381.26 4381.26 champus insurance champus Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 champus insurance champus Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 5253.36 5253.36 champus insurance champus Analysis for antibody to mumps virus cpt 86735 27.36 27.36 11.61 11.61 53.93 53.93 44.94 44.94 O 13.1 13.1 champus insurance champus "Insertion of hardware to broken finger or thumb, accessed through the skin" cpt 26756 2425.05 2425.05 2425.05 2425.05 23510.05 23510.05 19591.71 19591.71 E 2425.05 2425.05 champus insurance champus Closed treatment of dislocated finger joint with manipulation cpt 26770 445.78 445.78 445.78 445.78 2172.47 2172.47 1810.39 1810.39 E 445.78 445.78 champus insurance champus simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 6293.35 6293.35 champus insurance champus Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 14.45 14.45 champus insurance champus "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 326.12 326.12 champus insurance champus "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 326.12 326.12 champus insurance champus Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 12.93 12.93 champus insurance champus Injection of dye for X-ray imaging of hip joint cpt 27093 639.83 639.83 332.86 332.86 5036.53 5036.53 4197.11 4197.11 O 639.83 639.83 champus insurance champus normal newborn ms-drg 795 2082.25 2082.25 707.81 707.81 4256.4 4256.4 3547 3547 I 707.81 707.81 champus insurance champus Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 champus insurance champus Injection procedure into sacroiliac joint for anesthetic or steroid cpt 27096 1079.07 1079.07 1079.07 1079.07 4992.34 4992.34 4160.28 4160.28 O 1079.07 1079.07 champus insurance champus Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 12.93 12.93 champus insurance champus Closed treatment of dislocation of knee cap cpt 27560 584.06 584.06 293.55 293.55 2430.83 2430.83 2025.69 2025.69 E 584.06 584.06 champus insurance champus "Insertion of hardware to broken thigh bone, accessed through the skin" cpt 27235 5384.14 5384.14 5384.14 5384.14 34760.02 34760.02 28966.68 28966.68 O 5384.14 5384.14 champus insurance champus chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 6232.72 6232.72 champus insurance champus "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 426.6 426.6 champus insurance champus pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 3622.47 3622.47 champus insurance champus Removal of foreign body of thigh or knee cpt 27372 2054.26 2054.26 2054.26 2054.26 21281.98 21281.98 17734.98 17734.98 O 2054.26 2054.26 champus insurance champus Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.98 15.98 champus insurance champus Reconstruction of knee joint ligaments cpt 27427 5299.29 5299.29 5299.29 5299.29 54557.4 54557.4 45464.5 45464.5 O 5299.29 5299.29 champus insurance champus Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 14.33 14.33 champus insurance champus respiratory infections and inflammations without cc/mcc ms-drg 179 9651.21 9651.21 3828.24 3828.24 10946.44 10946.44 9122.03 9122.03 I 3828.24 3828.24 champus insurance champus Exploration of ankle joint cpt 27620 5299.29 5299.29 5299.29 5299.29 38340.77 38340.77 31950.64 31950.64 O 5299.29 5299.29 champus insurance champus pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 3391.36 3391.36 champus insurance champus Lengthening of calf muscle cpt 27687 3544.14 3544.14 2425.05 2425.05 29642.78 29642.78 24702.32 24702.32 O 2425.05 2425.05 champus insurance champus "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 25.92 25.92 champus insurance champus "Repair of disrupted collateral ligament of ankle, primary" cpt 27695 5299.29 5299.29 5299.29 5299.29 38121.77 38121.77 31768.14 31768.14 O 5299.29 5299.29 champus insurance champus Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 122.75 122.75 champus insurance champus "Repair of disrupted collateral ligament of ankle, secondary" cpt 27698 5299.29 5299.29 5299.29 5299.29 37155.17 37155.17 30962.64 30962.64 O 5299.29 5299.29 champus insurance champus other respiratory system o.r. procedures with cc ms-drg 167 18925.13 18925.13 5702.35 5702.35 57441.06 57441.06 47867.55 47867.55 I 5702.35 5702.35 champus insurance champus major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 11773.8 11773.8 champus insurance champus Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 43.82 43.82 champus insurance champus Identification of red blood cell antibodies cpt 86870 251.07 251.07 23.42 23.42 310.8 310.8 259 259 O 251.07 251.07 champus insurance champus cesarean section with sterilization without cc/mcc ms-drg 785 5437.77 5437.77 3250.27 3250.27 14747.66 14747.66 12289.72 12289.72 I 4184.04 4184.04 champus insurance champus Treatment of broken shin bone cpt 27759 10624.49 10624.49 10624.49 10624.49 39660.5 39660.5 33050.42 33050.42 O 10624.49 10624.49 champus insurance champus "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 29.61 29.61 champus insurance champus "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 209.39 209.39 champus insurance champus Correction of toe joint deformity cpt 28285 5299.29 5299.29 2405.65 2405.65 34078.68 34078.68 28398.9 28398.9 O 5299.29 5299.29 champus insurance champus major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 14423.44 14423.44 champus insurance champus Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 96.59 96.59 champus insurance champus "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 19.63 19.63 champus insurance champus major chest procedures with mcc ms-drg 163 28721.37 28721.37 15759.84 15759.84 142219.09 142219.09 118515.91 118515.91 I 25423.48 25423.48 champus insurance champus dental and oral diseases with cc ms-drg 158 9311.37 9311.37 3170.15 3170.15 23073.84 23073.84 19228.2 19228.2 I 4912.52 4912.52 champus insurance champus cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 5248.85 5248.85 champus insurance champus otitis media and uri without mcc ms-drg 153 5161.07 5161.07 1899.95 1899.95 22377.64 22377.64 18648.03 18648.03 I 3135.8 3135.8 champus insurance champus Open treatment of the inside prominence of bone of the leg (fibula) in the region of the ankle cpt 27766 5299.29 5299.29 5299.29 5299.29 28443.89 28443.89 23703.24 23703.24 O 5299.29 5299.29 champus insurance champus "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 477.34 477.34 champus insurance champus Open treatment of the outer bone of the lower leg cpt 27784 5299.29 5299.29 5299.29 5299.29 28098.41 28098.41 23415.34 23415.34 O 5299.29 5299.29 champus insurance champus cesarean section with sterilization with mcc ms-drg 783 7624.57 7624.57 4760.84 4760.84 22017.84 22017.84 18348.2 18348.2 I 7624.57 7624.57 champus insurance champus Removal of skin and/or muscle first 20 sq cm or less cpt 11043 440.3 440.3 433.26 433.26 2436.26 2436.26 2030.22 2030.22 O 440.3 440.3 champus insurance champus Open treatment of the outside prominence of bone of the leg (fibula) in the region of the ankle cpt 27792 7125.29 7125.29 4890.06 4890.06 32793.31 32793.31 27327.76 27327.76 O 5299.29 5299.29 champus insurance champus Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 2546.76 2546.76 champus insurance champus Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.42 39.42 champus insurance champus Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 9.34 9.34 champus insurance champus Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 13118.87 13118.87 champus insurance champus Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 296.91 296.91 champus insurance champus Incision of tissues of muscle compartment of foot and/or toe cpt 28008 3179.01 3179.01 2425.05 2425.05 14330.89 14330.89 11942.41 11942.41 O 2425.05 2425.05 champus insurance champus postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 2725.99 2725.99 champus insurance champus Bacterial blood culture cpt 87040 233.73 233.73 9.18 9.18 280.48 280.48 233.73 233.73 E 233.73 233.73 champus insurance champus Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 10.36 10.36 champus insurance champus Removal or scraping of bone cyst or growth of heel bone with donor bone graft cpt 28103 5299.29 5299.29 5299.29 5299.29 22238.88 22238.88 18532.4 18532.4 O 5299.29 5299.29 champus insurance champus Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 9.48 9.48 champus insurance champus SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.54 51.54 champus insurance champus Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 112.14 112.14 champus insurance champus "abortion with d&c, aspiration curettage or hysterotomy" ms-drg 770 4565.54 4565.54 4253.56 4253.56 23003.7 23003.7 19169.75 19169.75 I 4253.56 4253.56 champus insurance champus Partial removal of foot or heel bone for bone infection in the midfoot area cpt 28122 2425.05 2425.05 2425.05 2425.05 22013.7 22013.7 18344.75 18344.75 O 2425.05 2425.05 champus insurance champus SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 249.39 249.39 champus insurance champus vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 3175.22 3175.22 champus insurance champus Repair of foot tendon on the sole of the foot without a graft cpt 28200 2425.05 2425.05 2425.05 2425.05 22256.16 22256.16 18546.8 18546.8 O 2425.05 2425.05 champus insurance champus Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 22.32 22.32 champus insurance champus ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 991.98 991.98 champus insurance champus ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1952.13 1952.13 champus insurance champus "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.48 9.48 champus insurance champus Correction of bunion with removal of the base of the great toe cpt 28292 3561.38 3561.38 2425.05 2425.05 37116.88 37116.88 30930.73 30930.73 O 2425.05 2425.05 champus insurance champus "Correction of bunion, with alignment correction of midfoot bone (metatarsal) towards toe areas" cpt 28296 5299.29 5299.29 2425.05 2425.05 21810.48 21810.48 18175.4 18175.4 O 5299.29 5299.29 champus insurance champus intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6856.49 6856.49 champus insurance champus Amputation of toe and midfoot bone cpt 28810 2425.05 2425.05 2386.25 2386.25 18552.49 18552.49 15460.41 15460.41 O 2425.05 2425.05 champus insurance champus "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 311.64 311.64 138.5 138.5 1779.53 1779.53 1482.94 1482.94 E 254.75 254.75 champus insurance champus "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 6.54 6.54 champus insurance champus "Application of non-moveable, hinged finger splint" cpt 29130 197.85 197.85 197.85 197.85 1704.72 1704.72 1420.6 1420.6 E 197.85 197.85 champus insurance champus "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 8.66 8.66 champus insurance champus Application of short leg splint (calf to foot) cpt 29515 402.03 402.03 239.29 239.29 1787.76 1787.76 1489.8 1489.8 E 316.33 316.33 champus insurance champus Incision of should joint capsule using an endoscope cpt 29806 5299.29 5299.29 5299.29 5299.29 40696.28 40696.28 33913.57 33913.57 O 5299.29 5299.29 champus insurance champus "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.32 27.32 champus insurance champus "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 9.51 9.51 champus insurance champus Bacterial culture for anaerobic isolates cpt 87076 8.11 8.11 7.19 7.19 103.92 103.92 86.6 86.6 O 8.11 8.11 champus insurance champus "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 champus insurance champus Repair of shoulder socket cartilage using an endoscope cpt 29807 5299.29 5299.29 5299.29 5299.29 41843.26 41843.26 34869.38 34869.38 O 5299.29 5299.29 champus insurance champus "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 14.76 14.76 champus insurance champus Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 2425.05 2425.05 champus insurance champus Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.11 8.11 champus insurance champus inflammation of the male reproductive system without mcc ms-drg 728 6665.67 6665.67 2407.15 2407.15 11957.9 11957.9 9964.92 9964.92 I 2407.15 2407.15 champus insurance champus Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 2425.05 2425.05 champus insurance champus Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 5299.29 5299.29 champus insurance champus Release or removal of shoulder scar tissue using an endoscope cpt 29825 5550.48 5550.48 2405.65 2405.65 31991.54 31991.54 26659.62 26659.62 O 2425.05 2425.05 champus insurance champus Cardiac valve and other major cardiothoracic procedures ms-drg 216 57813.21 57813.21 57090.86 57090.86 223866.24 223866.24 186555.2 186555.2 I 57090.86 57090.86 champus insurance champus Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 5299.29 5299.29 champus insurance champus Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 21.3 21.3 champus insurance champus Release of shoulder biceps tendon using an endoscope cpt 29828 6466.87 6466.87 5299.29 5299.29 38752.94 38752.94 32294.12 32294.12 O 5299.29 5299.29 champus insurance champus Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 6.66 6.66 champus insurance champus Removal of loose or foreign body of knee joint using an endoscope cpt 29874 2425.05 2425.05 2425.05 2425.05 20644.62 20644.62 17203.85 17203.85 O 2425.05 2425.05 champus insurance champus Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 12.63 12.63 champus insurance champus Partial removal of knee joint lining using an endoscope cpt 29875 5454.29 5454.29 3862.17 3862.17 24288.23 24288.23 20240.19 20240.19 O 3862.17 3862.17 champus insurance champus Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 champus insurance champus Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 2425.05 2425.05 champus insurance champus Repair of knee joint with drilling and or scraping of the joint cpt 29879 2425.05 2425.05 2425.05 2425.05 19707.74 19707.74 16423.12 16423.12 O 2425.05 2425.05 champus insurance champus Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 champus insurance champus Repair of inside OR outside knee joint cartilage (meniscus) using an endoscope (arthroscopy) cpt 29882 10542.6 10542.6 2386.25 2386.25 33847.09 33847.09 28205.91 28205.91 O 10542.6 10542.6 champus insurance champus Repair of anterior cruciate ligament of knee with assistance of an endoscope cpt 29888 5299.29 5299.29 4948.03 4948.03 52105.64 52105.64 43421.37 43421.37 O 5299.29 5299.29 champus insurance champus Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 316.47 316.47 champus insurance champus "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.1 8.1 champus insurance champus Removal of dead or infected ankle joint tissue using an endoscope cpt 29898 5299.29 5299.29 5299.29 5299.29 42780.92 42780.92 35650.77 35650.77 O 5299.29 5299.29 champus insurance champus "Removal of polyps in nose, extensive or complex" cpt 30115 7551.65 7551.65 4819.51 4819.51 49945.48 49945.48 41621.23 41621.23 O 4819.51 4819.51 champus insurance champus Nasal procedure cpt 30999 4819.51 4819.51 4819.51 4819.51 47279.42 47279.42 39399.52 39399.52 O 4819.51 4819.51 champus insurance champus Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 41.45 41.45 champus insurance champus Partial removal of nasal sinus using an endoscope cpt 31254 6790.97 6790.97 4819.51 4819.51 43785.56 43785.56 36487.97 36487.97 O 4819.51 4819.51 champus insurance champus Culture for acid-fast bacilli cpt 87116 10.84 10.84 9.61 9.61 122.11 122.11 101.76 101.76 O 10.84 10.84 champus insurance champus "Removal of nasal sinus tissue using an endoscope, maxillary sinus" cpt 31267 6790.97 6790.97 4819.51 4819.51 34277.41 34277.41 28564.51 28564.51 O 4819.51 4819.51 champus insurance champus Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 2333.86 2333.86 champus insurance champus "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.2 5.2 champus insurance champus Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1409.82 1409.82 champus insurance champus Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1103.22 1103.22 champus insurance champus "Removal of fluid from between lung and chest cavity, open procedure" cpt 32551 1444.99 1444.99 1444.99 1444.99 3324.37 3324.37 2770.31 2770.31 E 1444.99 1444.99 champus insurance champus Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 22360.86 22360.86 champus insurance champus "Insertion of catheter into abdominal pelvic or leg artery, each first order branch" cpt 36245 2455.02 2455.02 125.31 125.31 25382.86 25382.86 21152.38 21152.38 O 2455.02 2455.02 champus insurance champus Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1215.96 1215.96 champus insurance champus Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 474.41 474.41 champus insurance champus amniotic membrane cpt V2790 1714.35 1714.35 1714.35 1714.35 20400.06 20400.06 17000.05 17000.05 O 1714.35 1714.35 champus insurance champus Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 8.94 8.94 champus insurance champus "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 179.27 179.27 champus insurance champus post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 1791.13 1791.13 champus insurance champus poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 7443.75 7443.75 champus insurance champus "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 4.77 4.77 champus insurance champus Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 224.29 224.29 champus insurance champus CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 99.29 99.29 champus insurance champus contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 1791.13 1791.13 champus insurance champus major male pelvic procedures with cc/mcc ms-drg 707 13215.8 13215.8 10639.1 10639.1 62125.99 62125.99 51771.66 51771.66 I 12596.93 12596.93 champus insurance champus "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.69 8.69 champus insurance champus robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 4282.09 4282.09 champus insurance champus "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1103.22 1103.22 champus insurance champus "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 3619.14 3619.14 champus insurance champus visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 3661.72 3661.72 champus insurance champus "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 2683.82 2683.82 champus insurance champus Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.29 4.29 champus insurance champus Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 70.7 70.7 champus insurance champus Special stain for inclusion bodies or parasites cpt 87207 6.01 6.01 6.01 6.01 19.98 19.98 16.65 16.65 O 6.01 6.01 champus insurance champus "locm 200-299mg/ml iodine,1ml" cpt Q9966 8777.72 8777.72 1362.44 1362.44 45290.62 45290.62 37742.18 37742.18 O 8777.72 8777.72 champus insurance champus "locm 200-299mg/ml iodine,1ml" cpt Q9966 14120.9 14120.9 8777.72 8777.72 75967.02 75967.02 63305.85 63305.85 E 8791.16 8791.16 champus insurance champus "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 285.09 285.09 champus insurance champus "hocm 250-299mg/ml iodine,1ml" cpt Q9961 206.45 206.45 206.45 206.45 3408.2 3408.2 2840.17 2840.17 O 206.45 206.45 champus insurance champus "hocm <=149 mg/ml iodine, 1ml" cpt Q9958 309.68 309.68 206.45 206.45 2947.64 2947.64 2456.37 2456.37 O 206.45 206.45 champus insurance champus Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.76 4.76 champus insurance champus Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 34 34 champus insurance champus urinary stones without mcc ms-drg 694 5014.21 5014.21 2963.72 2963.72 12824.16 12824.16 10686.8 10686.8 I 3248.11 3248.11 champus insurance champus Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 812.68 812.68 champus insurance champus Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 12.03 12.03 champus insurance champus grafix stravix prime pl sqcm cpt Q4133 1523.14 1523.14 1437.55 1437.55 6559.3 6559.3 5466.08 5466.08 O 1523.14 1523.14 champus insurance champus "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 18.13 18.13 champus insurance champus "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 champus insurance champus "albumin (human), 5%, 250 ml" cpt P9045 10542.6 10542.6 2181.31 2181.31 30719.15 30719.15 25599.29 25599.29 O 10542.6 10542.6 champus insurance champus other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 10882.61 10882.61 champus insurance champus Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 408.55 408.55 champus insurance champus plasma 1 donor frz w/in 8 hr cpt P9017 2415.74 2415.74 1444.99 1444.99 27667.37 27667.37 23056.14 23056.14 O 1444.99 1444.99 champus insurance champus rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 979.86 979.86 champus insurance champus Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 champus insurance champus rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 champus insurance champus "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 112.14 112.14 champus insurance champus CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 champus insurance champus Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.37 10.37 champus insurance champus Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 98.51 98.51 champus insurance champus so acro/clav can web pre ots cpt L3670 16498.51 16498.51 5299.29 5299.29 37379.68 37379.68 31149.73 31149.73 O 5299.29 5299.29 champus insurance champus Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1444.99 1444.99 champus insurance champus so 8 ab rstr can/web pre ots cpt L3660 9596.97 9596.97 4859.91 4859.91 40126.92 40126.92 33439.1 33439.1 O 5299.29 5299.29 champus insurance champus "Removal of growth (1.1 to 2.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11422 1215.96 1215.96 1196.5 1196.5 16080.52 16080.52 13400.43 13400.43 O 1215.96 1215.96 champus insurance champus kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 3565.19 3565.19 champus insurance champus Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 24.18 24.18 champus insurance champus "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 99.29 99.29 champus insurance champus ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 102.7 102.7 champus insurance champus kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 6312.25 6312.25 champus insurance champus Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 12.03 12.03 champus insurance champus Injection of chemical agent into multiple incompetent veins of one leg cpt 36471 12086.89 12086.89 240.32 240.32 499.13 499.13 415.94 415.94 O 2455.02 2455.02 champus insurance champus ko adj jnt pos r sup pre ots cpt L1833 5299.29 5299.29 4915.71 4915.71 41050.93 41050.93 34209.11 34209.11 O 5299.29 5299.29 champus insurance champus cerv flex n/adj foam pre ots cpt L0120 10542.6 10542.6 10359.91 10359.91 55458.7 55458.7 46215.58 46215.58 O 10542.6 10542.6 champus insurance champus "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 1752.77 1752.77 champus insurance champus "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 2455.02 2455.02 champus insurance champus vincristine sulfate 1 mg inj cpt J9370 11286.59 11286.59 9665.8 9665.8 53792.88 53792.88 44827.4 44827.4 O 11286.59 11286.59 champus insurance champus vinblastine sulfate inj cpt J9360 10076.53 10076.53 758.2 758.2 5234.28 5234.28 4361.9 4361.9 O 758.2 758.2 champus insurance champus "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 champus insurance champus inj trastuzumab excl biosimi cpt J9355 11920.99 11920.99 4839.22 4839.22 26839.2 26839.2 22366 22366 O 10425.7 10425.7 champus insurance champus "injection, pertuzumab, 1 mg" cpt J9306 23772.44 23772.44 10140.03 10140.03 46463.62 46463.62 38719.68 38719.68 O 10425.7 10425.7 champus insurance champus "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 champus insurance champus "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.13 20.13 champus insurance champus Analysis using chemiluminescent technique (light and chemical )reaction cpt 82397 14.18 14.18 6.55 6.55 58.19 58.19 48.49 48.49 O 14.18 14.18 champus insurance champus inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 8001.63 8001.63 champus insurance champus Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 127.01 127.01 champus insurance champus obinutuzumab inj cpt J9301 11286.59 11286.59 5283.13 5283.13 28931.02 28931.02 24109.18 24109.18 O 11286.59 11286.59 champus insurance champus paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 2981.53 2981.53 champus insurance champus "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.23 35.23 champus insurance champus Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 508.17 508.17 champus insurance champus splenectomy without cc/mcc ms-drg 801 7704.58 7704.58 7704.58 7704.58 46856.75 46856.75 39047.29 39047.29 I 7704.58 7704.58 champus insurance champus oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 938.77 938.77 champus insurance champus methotrexate sodium inj cpt J9260 1952.13 1952.13 529.47 529.47 5076.19 5076.19 4230.16 4230.16 E 1952.13 1952.13 champus insurance champus Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.65 14.65 champus insurance champus "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.42 37.42 champus insurance champus leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 751.73 751.73 champus insurance champus irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 8573.35 8573.35 champus insurance champus in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 341.79 341.79 champus insurance champus Carcinoembryonic antigen (CEA) protein level cpt 82378 34.13 34.13 16.86 16.86 137.4 137.4 114.5 114.5 O 19.04 19.04 champus insurance champus "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 1891.86 1891.86 champus insurance champus Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 1409.82 1409.82 champus insurance champus fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 8184.57 8184.57 champus insurance champus etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 1391.91 1391.91 champus insurance champus Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 146.68 146.68 champus insurance champus Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 638.4 638.4 champus insurance champus Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 20.95 20.95 champus insurance champus Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1409.82 1409.82 champus insurance champus Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 99.29 99.29 champus insurance champus dacarbazine 100 mg inj cpt J9130 810.71 810.71 758.2 758.2 5234.28 5234.28 4361.9 4361.9 O 758.2 758.2 champus insurance champus "Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11423 2631.83 2631.83 1215.96 1215.96 17605.97 17605.97 14671.64 14671.64 O 1215.96 1215.96 champus insurance champus "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.13 20.13 champus insurance champus "Ultrasound of pelvis, limited, not pregnancy related" cpt 76857 272.6 272.6 58.94 58.94 190.8 190.8 159 159 O 272.6 272.6 champus insurance champus cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 11286.59 11286.59 champus insurance champus cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 7923.09 7923.09 champus insurance champus cetuximab injection cpt J9055 5439.13 5439.13 2730.38 2730.38 16940.5 16940.5 14117.08 14117.08 O 4311.72 4311.72 champus insurance champus carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 2981.53 2981.53 champus insurance champus brentuximab vedotin inj cpt J9042 28140.84 28140.84 25901.14 25901.14 105462.79 105462.79 87885.66 87885.66 O 25901.14 25901.14 champus insurance champus bleomycin sulfate injection cpt J9040 851.54 851.54 791.36 791.36 5362.75 5362.75 4468.96 4468.96 O 791.36 791.36 champus insurance champus renal failure without cc/mcc ms-drg 684 10924.55 10924.55 3036.64 3036.64 15925.09 15925.09 13270.91 13270.91 I 3036.64 3036.64 champus insurance champus "Ultrasound of pelvis, complete, not pregnancy related" cpt 76856 99.29 99.29 63.46 63.46 703.42 703.42 586.18 586.18 E 99.29 99.29 champus insurance champus bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 8590.23 8590.23 champus insurance champus "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 2455.02 2455.02 champus insurance champus doxorubicin hcl injection cpt J9000 10076.53 10076.53 758.2 758.2 29950.2 29950.2 24958.5 24958.5 O 758.2 758.2 champus insurance champus "Detection test by nucleic acid for HIV-1 virus, quantification" cpt 87536 489.72 489.72 75.7 75.7 559.68 559.68 466.4 466.4 O 94.94 94.94 champus insurance champus Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 99.29 99.29 champus insurance champus "Insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37226 14007.94 14007.94 8097.07 8097.07 92080.52 92080.52 76733.77 76733.77 O 8777.72 8777.72 champus insurance champus prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 268.55 268.55 champus insurance champus 5% dextrose in lac ringers cpt J7121 6073.23 6073.23 478.56 478.56 3035.82 3035.82 2529.85 2529.85 E 482.86 482.86 champus insurance champus ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 553.72 553.72 champus insurance champus "Removal of skin and tissue beneath the skin of underarms for excessive sweating, simple" cpt 11450 2054.26 2054.26 2054.26 2054.26 20861.16 20861.16 17384.3 17384.3 O 2054.26 2054.26 champus insurance champus "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.23 35.23 champus insurance champus Ultrasound and monitoring of heart of fetus cpt 76818 456.54 456.54 99.29 99.29 928.56 928.56 773.8 773.8 O 99.29 99.29 champus insurance champus Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 99.29 99.29 champus insurance champus ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 612.63 612.63 champus insurance champus d5w infusion cpt J7070 3105.49 3105.49 210.36 210.36 7339.42 7339.42 6116.18 6116.18 O 3105.49 3105.49 champus insurance champus d5w infusion cpt J7070 3598.87 3598.87 589.26 589.26 12422.94 12422.94 10352.45 10352.45 E 3598.87 3598.87 champus insurance champus normal saline solution infus cpt J7050 1660.16 1660.16 196.53 196.53 3827.75 3827.75 3189.79 3189.79 O 196.53 196.53 champus insurance champus renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 4316.65 4316.65 champus insurance champus "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 39.15 39.15 champus insurance champus normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 630.41 630.41 champus insurance champus Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 4282.09 4282.09 champus insurance champus normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 696.23 696.23 champus insurance champus normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1200.71 1200.71 champus insurance champus Procalcitonin (hormone) level cpt 84145 87.98 87.98 24.21 24.21 105.58 105.58 87.98 87.98 E 87.98 87.98 champus insurance champus "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 35.23 35.23 champus insurance champus "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 4639.61 4639.61 champus insurance champus normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 2779.76 2779.76 champus insurance champus "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 39.15 39.15 champus insurance champus normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 578.87 578.87 champus insurance champus "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 2683.82 2683.82 champus insurance champus Open biopsy or excision of lymph nodes in groin cpt 38531 2683.82 2683.82 2640.88 2640.88 19339.18 19339.18 16115.98 16115.98 O 2683.82 2683.82 champus insurance champus "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 99.29 99.29 champus insurance champus "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 99.29 99.29 champus insurance champus inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 7923.09 7923.09 champus insurance champus Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 326.12 326.12 champus insurance champus inj potassium chloride cpt J3480 1971.24 1971.24 725.65 725.65 15041.03 15041.03 12534.19 12534.19 E 1952.13 1952.13 champus insurance champus Separation of single nail plate from nail bed cpt 11730 251.42 251.42 197.85 197.85 1029.65 1029.65 858.04 858.04 E 197.85 197.85 champus insurance champus inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 1524.42 1524.42 champus insurance champus "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.13 20.13 champus insurance champus "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 37.19 37.19 champus insurance champus Carboxyhemoglobin (protein) level cpt 82375 98.58 98.58 10.96 10.96 118.3 118.3 98.58 98.58 E 98.58 98.58 champus insurance champus Relocation of mouth tissue to gum surface cpt 41899 180.4 180.4 0.99 0.99 15461.33 15461.33 12884.44 12884.44 O 180.4 180.4 champus insurance champus inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 1515.9 1515.9 champus insurance champus other kidney and urinary tract procedures with cc ms-drg 674 19025.41 19025.41 12967.56 12967.56 50807.44 50807.44 42339.53 42339.53 I 12967.56 12967.56 champus insurance champus vitamin k phytonadione inj cpt J3430 4902.1 4902.1 1444.99 1444.99 24968.99 24968.99 20807.49 20807.49 O 1444.99 1444.99 champus insurance champus other kidney and urinary tract procedures with mcc ms-drg 673 28002.28 28002.28 19960.91 19960.91 92745.01 92745.01 77287.51 77287.51 I 28002.28 28002.28 champus insurance champus Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 99.29 99.29 champus insurance champus "Removal of foreign bodies of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43247 1508.74 1508.74 1078.57 1078.57 5734.02 5734.02 4778.35 4778.35 E 1508.74 1508.74 champus insurance champus vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 102.7 102.7 champus insurance champus "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 28.14 28.14 champus insurance champus Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 39.34 39.34 champus insurance champus thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 508.17 508.17 champus insurance champus hydroxyzine hcl injection cpt J3410 466.82 466.82 233.2 233.2 1913.71 1913.71 1594.76 1594.76 E 233.2 233.2 champus insurance champus Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 1044.35 1044.35 champus insurance champus vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 3862.17 3862.17 champus insurance champus diazepam injection cpt J3360 3915.09 3915.09 53.57 53.57 9478.99 9478.99 7899.16 7899.16 O 53.57 53.57 champus insurance champus "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 champus insurance champus triamcinolone acet inj nos cpt J3301 4701.08 4701.08 231.9 231.9 774.72 774.72 645.6 645.6 O 231.9 231.9 champus insurance champus Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 255.2 255.2 61.35 61.35 408.31 408.31 340.26 340.26 E 99.29 99.29 champus insurance champus tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 14120.9 14120.9 champus insurance champus tirofiban hcl cpt J3246 13879.76 13879.76 8791.16 8791.16 92266.52 92266.52 76888.77 76888.77 E 8791.16 8791.16 champus insurance champus Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 19.46 19.46 champus insurance champus Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 7453.01 7453.01 champus insurance champus chlorpromazine hcl injection cpt J3230 644.4 644.4 197.85 197.85 2857.18 2857.18 2380.98 2380.98 E 197.85 197.85 champus insurance champus Repair of hernia of muscle at esophagus and stomach using an endoscope cpt 43281 7453.01 7453.01 7332.11 7332.11 41985.52 41985.52 34987.93 34987.93 O 7453.01 7453.01 champus insurance champus kidney and ureter procedures for non-neoplasm without cc/mcc ms-drg 661 24215.64 24215.64 5983.11 5983.11 43738.31 43738.31 36448.59 36448.59 I 6870.84 6870.84 champus insurance champus "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.69 3.69 champus insurance champus fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 2674.06 2674.06 champus insurance champus Removal of appendix using an endoscope cpt 44970 21270.9 21270.9 4222.64 4222.64 35680.25 35680.25 29733.54 29733.54 E 4282.09 4282.09 champus insurance champus fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 1088.96 1088.96 champus insurance champus "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 43.82 43.82 champus insurance champus Removal of appendix using an endoscope cpt 44970 4282.09 4282.09 4133.64 4133.64 38493.3 38493.3 32077.75 32077.75 O 4282.09 4282.09 champus insurance champus methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 196.53 196.53 champus insurance champus Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 676.71 676.71 champus insurance champus methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 394.38 394.38 champus insurance champus methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1952.13 1952.13 champus insurance champus "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 99.29 99.29 champus insurance champus na ferric gluconate complex cpt J2916 2415.74 2415.74 1952.13 1952.13 18008.15 18008.15 15006.79 15006.79 E 1952.13 1952.13 champus insurance champus "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.18 5.18 champus insurance champus Removal of nail cpt 11750 594.69 594.69 480.9 480.9 1124.98 1124.98 937.48 937.48 E 480.9 480.9 champus insurance champus Rabies immune globulin for injection beneath the skin and/or into muscle cpt 90375 4276.88 4276.88 368.14 368.14 9260.98 9260.98 7717.48 7717.48 E 4276.88 4276.88 champus insurance champus "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 champus insurance champus "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1334.43 1334.43 champus insurance champus ropivacaine hcl injection cpt J2795 7567.25 7567.25 4940.62 4940.62 35964.18 35964.18 29970.15 29970.15 O 5299.29 5299.29 champus insurance champus rho d immune globulin inj cpt J2790 581.2 581.2 361.29 361.29 3862.79 3862.79 3218.99 3218.99 E 361.29 361.29 champus insurance champus "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 70.7 70.7 champus insurance champus regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1127.01 1127.01 champus insurance champus Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 18.87 18.87 champus insurance champus multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5135.56 5135.56 champus insurance champus "alcohol, drug abuse or dependence without rehabilitation therapy with mcc" ms-drg 896 14293.05 14293.05 6299.39 6299.39 44680.85 44680.85 37234.04 37234.04 I 6514.56 6514.56 champus insurance champus "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 3.69 3.69 champus insurance champus "Drainage of rectal abscess, superficial, surrounding the anus" cpt 46050 874.56 874.56 798.85 798.85 1153.27 1153.27 961.06 961.06 E 874.56 874.56 champus insurance champus "alcohol, drug abuse or dependence, left ama" ms-drg 894 1890.8 1890.8 1818.6 1818.6 16920.46 16920.46 14100.38 14100.38 I 1890.8 1890.8 champus insurance champus regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.57 1965.57 champus insurance champus Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 6.15 6.15 champus insurance champus kidney and ureter procedures for neoplasm with cc ms-drg 657 19461.2 19461.2 11797.09 11797.09 55709.35 55709.35 46424.46 46424.46 I 13552.29 13552.29 champus insurance champus ranitidine hydrochloride inj cpt J2780 562.1 562.1 451.28 451.28 2485.64 2485.64 2071.37 2071.37 E 451.28 451.28 champus insurance champus Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 7.98 7.98 champus insurance champus "Semen evaluation volume, sperm count, motility and analysis" cpt 89320 127.99 127.99 12.36 12.36 146.28 146.28 121.9 121.9 O 12.36 12.36 champus insurance champus "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 38.66 38.66 champus insurance champus Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 222.96 222.96 champus insurance champus metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 2425.05 2425.05 champus insurance champus Removal of external hemorrhoids by rubber banding cpt 46221 17972.06 17972.06 676.71 676.71 5123.33 5123.33 4269.44 4269.44 O 676.71 676.71 champus insurance champus Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 1113.96 1113.96 champus insurance champus Administration of vaccine cpt 90472 4295.94 4295.94 368.14 368.14 10250.63 10250.63 8542.19 8542.19 E 4083.29 4083.29 champus insurance champus metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 575.69 575.69 champus insurance champus Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 champus insurance champus psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 1842.42 1842.42 champus insurance champus inj protamine sulfate/10 mg cpt J2720 1523.14 1523.14 1523.14 1523.14 27765.84 27765.84 23138.2 23138.2 O 1523.14 1523.14 champus insurance champus Vaccine for rabies injection into skin cpt 90676 4295.94 4295.94 229.65 229.65 1669.33 1669.33 1391.11 1391.11 E 425.38 425.38 champus insurance champus "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 2010.24 2010.24 617.1 617.1 19339.78 19339.78 16116.48 16116.48 E 2010.24 2010.24 champus insurance champus Removal of single external and internal hemorrhoid group cpt 46255 2076.66 2076.66 1557.5 1557.5 16490.1 16490.1 13741.75 13741.75 O 1557.5 1557.5 champus insurance champus "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 11116.59 11116.59 champus insurance champus Repair of finger or toe nail bed cpt 11760 2054.26 2054.26 1110.7 1110.7 19051.34 19051.34 15876.12 15876.12 O 2054.26 2054.26 champus insurance champus neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 4282.09 4282.09 champus insurance champus "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 222.96 222.96 champus insurance champus "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.78 10.78 champus insurance champus neostigmine methylslfte inj cpt J2710 21270.9 21270.9 4044.95 4044.95 34866.31 34866.31 29055.26 29055.26 E 4282.09 4282.09 champus insurance champus "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 1052.97 1052.97 champus insurance champus "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.9 17.9 champus insurance champus "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 304.08 304.08 143.86 143.86 1881.6 1881.6 1568 1568 O 230.49 230.49 champus insurance champus Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2455.02 2455.02 champus insurance champus Evaluation of speech sound production with evaluation of language comprehension and expression cpt 92523 2123.04 2123.04 1479.91 1479.91 16598.95 16598.95 13832.46 13832.46 E 1967.07 1967.07 champus insurance champus Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 28.22 28.22 champus insurance champus Evaluation of speech sound production with evaluation of language comprehension and expression cpt 92523 294 294 71.93 71.93 1205.17 1205.17 1004.31 1004.31 O 266.76 266.76 champus insurance champus "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 3863.46 3863.46 champus insurance champus "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 197.85 197.85 champus insurance champus Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2136.63 2136.63 champus insurance champus "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1569.38 1569.38 champus insurance champus Serotonin (hormone) level cpt 84260 31.11 31.11 30.98 30.98 253.13 253.13 210.94 210.94 O 31.11 31.11 champus insurance champus "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 7102.03 7102.03 champus insurance champus Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 250.66 250.66 champus insurance champus Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 28.05 28.05 champus insurance champus septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 4743.96 4743.96 champus insurance champus "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14000.33 14000.33 8792.66 8792.66 92266.52 92266.52 76888.77 76888.77 E 8792.66 8792.66 champus insurance champus diabetes without cc/mcc ms-drg 639 6905 6905 2716.05 2716.05 25004.18 25004.18 20836.82 20836.82 I 2760.03 2760.03 champus insurance champus Radiological supervision and interpretation X-ray of uterine tubes and ovaries cpt 74740 206.45 206.45 206.45 206.45 1211.23 1211.23 1009.36 1009.36 O 206.45 206.45 champus insurance champus "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 14120.9 14120.9 champus insurance champus "Radiological supervision and interpretation X-ray of urinary bladder and urethra, emptying" cpt 74455 206.45 206.45 62.56 62.56 1086.29 1086.29 905.24 905.24 O 206.45 206.45 champus insurance champus "Ultrasound evaluation of heart blood vessel or graft, each additional vessel" cpt 92979 14120.9 14120.9 172.42 172.42 114856.13 114856.13 95713.44 95713.44 O 14120.9 14120.9 champus insurance champus Attempt to restart heart and lungs cpt 92950 2333.86 2333.86 671.16 671.16 3861.56 3861.56 3217.97 3217.97 E 2333.86 2333.86 champus insurance champus Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.75 9.75 champus insurance champus Imaging of urinary tract using infusion technique with kidney section filming cpt 74415 161.43 161.43 160.14 160.14 1024.8 1024.8 854 854 O 161.43 161.43 champus insurance champus External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 475.24 475.24 champus insurance champus Chemical analysis using spectrophotometry (light) cpt 84311 8.13 8.13 7.2 7.2 24.3 24.3 20.25 20.25 O 8.13 8.13 champus insurance champus Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 311.64 311.64 champus insurance champus Removal of multiple internal and external hemorrhoid groups cpt 46260 2076.66 2076.66 1955.05 1955.05 18954.95 18954.95 15795.79 15795.79 O 2076.66 2076.66 champus insurance champus "Repair of abnormal anal drainage tract, under the skin" cpt 46270 2076.66 2076.66 2076.66 2076.66 17699.64 17699.64 14749.7 14749.7 O 2076.66 2076.66 champus insurance champus "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 2333.86 2333.86 champus insurance champus piperacillin/tazobactam cpt J2543 4282.09 4282.09 389.58 389.58 13027.27 13027.27 10856.06 10856.06 O 4282.09 4282.09 champus insurance champus Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 33.44 33.44 cigna ppo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 33.44 33.44 cigna hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 33.44 33.44 cigna pos Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 33.44 33.44 cigna epo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1815.3 1815.3 cigna ppo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1815.3 1815.3 cigna hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1815.3 1815.3 cigna pos MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1815.3 1815.3 cigna epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 7986.58 7986.58 cigna ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 7986.58 7986.58 cigna hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 7986.58 7986.58 cigna pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 7986.58 7986.58 cigna epo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 692.28 692.28 cigna ppo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 692.28 692.28 cigna hmo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 692.28 692.28 cigna pos "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 692.28 692.28 cigna epo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 21270.9 21270.9 cigna ppo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 21270.9 21270.9 cigna hmo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 21270.9 21270.9 cigna pos hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 21270.9 21270.9 cigna epo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 104.77 104.77 cigna ppo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 104.77 104.77 cigna hmo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 104.77 104.77 cigna pos Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 104.77 104.77 cigna epo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 34704.54 34704.54 cigna ppo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 34704.54 34704.54 cigna hmo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 34704.54 34704.54 cigna pos infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 34704.54 34704.54 cigna epo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 19270.59 19270.59 cigna ppo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 19270.59 19270.59 cigna hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 19270.59 19270.59 cigna pos "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 19270.59 19270.59 cigna epo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4844.02 4844.02 cigna ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4844.02 4844.02 cigna hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4844.02 4844.02 cigna pos Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4844.02 4844.02 cigna epo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1623.33 1623.33 cigna ppo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1623.33 1623.33 cigna hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1623.33 1623.33 cigna pos Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1623.33 1623.33 cigna epo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4844.02 4844.02 cigna ppo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4844.02 4844.02 cigna hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4844.02 4844.02 cigna pos Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4844.02 4844.02 cigna epo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.78 26.78 cigna ppo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.78 26.78 cigna hmo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.78 26.78 cigna pos Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 26.78 26.78 cigna epo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15331.93 15331.93 cigna ppo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15331.93 15331.93 cigna hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15331.93 15331.93 cigna pos septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15331.93 15331.93 cigna epo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 81.95 81.95 cigna ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 81.95 81.95 cigna hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 81.95 81.95 cigna pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 81.95 81.95 cigna epo "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 21270.9 21270.9 cigna ppo "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 21270.9 21270.9 cigna hmo "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 21270.9 21270.9 cigna pos "inj, propofol, 10 mg" cpt J2704 21270.9 21270.9 1218.97 1218.97 23712.79 23712.79 19760.66 19760.66 E 21270.9 21270.9 cigna epo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 4844.02 4844.02 cigna ppo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 4844.02 4844.02 cigna hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 4844.02 4844.02 cigna pos "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 4844.02 4844.02 cigna epo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 63.9 63.9 cigna ppo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 63.9 63.9 cigna hmo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 63.9 63.9 cigna pos "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 63.9 63.9 cigna epo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 44.96 44.96 cigna ppo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 44.96 44.96 cigna hmo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 44.96 44.96 cigna pos "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 44.96 44.96 cigna epo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 4844.02 4844.02 cigna ppo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 4844.02 4844.02 cigna hmo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 4844.02 4844.02 cigna pos Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 4844.02 4844.02 cigna epo X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 315.06 315.06 cigna ppo X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 315.06 315.06 cigna hmo X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 315.06 315.06 cigna pos X-ray of upper digestive tract with single contrast and multiple serial films cpt 74250 315.06 315.06 75.49 75.49 539.33 539.33 449.44 449.44 O 315.06 315.06 cigna epo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5139.62 5139.62 cigna ppo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5139.62 5139.62 cigna hmo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5139.62 5139.62 cigna pos depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 5139.62 5139.62 cigna epo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 48.3 48.3 cigna ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 48.3 48.3 cigna hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 48.3 48.3 cigna pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 48.3 48.3 cigna epo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 26.01 26.01 cigna ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 26.01 26.01 cigna hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 26.01 26.01 cigna pos Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 26.01 26.01 cigna epo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 19270.59 19270.59 cigna ppo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 19270.59 19270.59 cigna hmo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 19270.59 19270.59 cigna pos neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 19270.59 19270.59 cigna epo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3539.01 3539.01 cigna ppo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3539.01 3539.01 cigna hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3539.01 3539.01 cigna pos "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 3539.01 3539.01 cigna epo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 1130.86 1130.86 cigna ppo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 1130.86 1130.86 cigna hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 1130.86 1130.86 cigna pos "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 1130.86 1130.86 cigna epo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52182.52 52182.52 cigna ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52182.52 52182.52 cigna hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52182.52 52182.52 cigna pos percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52182.52 52182.52 cigna epo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 608.56 608.56 cigna ppo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 608.56 608.56 cigna hmo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 608.56 608.56 cigna pos Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 608.56 608.56 cigna epo normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 8278.58 8278.58 cigna ppo normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 8278.58 8278.58 cigna hmo normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 8278.58 8278.58 cigna pos normal saline solution infus cpt J7050 8278.58 8278.58 598.59 598.59 11044.52 11044.52 9203.77 9203.77 E 8278.58 8278.58 cigna epo neostigmine methylslfte inj cpt J2710 21270.9 21270.9 4044.95 4044.95 34866.31 34866.31 29055.26 29055.26 E 21270.9 21270.9 cigna ppo neostigmine methylslfte inj cpt J2710 21270.9 21270.9 4044.95 4044.95 34866.31 34866.31 29055.26 29055.26 E 21270.9 21270.9 cigna hmo neostigmine methylslfte inj cpt J2710 21270.9 21270.9 4044.95 4044.95 34866.31 34866.31 29055.26 29055.26 E 21270.9 21270.9 cigna pos neostigmine methylslfte inj cpt J2710 21270.9 21270.9 4044.95 4044.95 34866.31 34866.31 29055.26 29055.26 E 21270.9 21270.9 cigna epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 16.35 16.35 cigna ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 16.35 16.35 cigna hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 16.35 16.35 cigna pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 16.35 16.35 cigna epo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 3539.01 3539.01 cigna ppo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 3539.01 3539.01 cigna hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 3539.01 3539.01 cigna pos normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 3539.01 3539.01 cigna epo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 141.92 141.92 cigna ppo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 141.92 141.92 cigna hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 141.92 141.92 cigna pos "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 141.92 141.92 cigna epo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 19270.59 19270.59 cigna ppo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 19270.59 19270.59 cigna hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 19270.59 19270.59 cigna pos morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 19270.59 19270.59 cigna epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3225.5 3225.5 cigna ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3225.5 3225.5 cigna hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3225.5 3225.5 cigna pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3225.5 3225.5 cigna epo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 41.02 41.02 cigna ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 41.02 41.02 cigna hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 41.02 41.02 cigna pos "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 41.02 41.02 cigna epo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna ppo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna hmo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna pos Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna epo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 4844.02 4844.02 cigna ppo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 4844.02 4844.02 cigna hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 4844.02 4844.02 cigna pos Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 4844.02 4844.02 cigna epo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 63.83 63.83 cigna ppo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 63.83 63.83 cigna hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 63.83 63.83 cigna pos Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 63.83 63.83 cigna epo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 448.08 448.08 cigna ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 448.08 448.08 cigna hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 448.08 448.08 cigna pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 448.08 448.08 cigna epo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5460.04 5460.04 cigna ppo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5460.04 5460.04 cigna hmo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5460.04 5460.04 cigna pos normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5460.04 5460.04 cigna epo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 80.4 80.4 cigna ppo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 80.4 80.4 cigna hmo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 80.4 80.4 cigna pos Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 80.4 80.4 cigna epo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 216.97 216.97 cigna ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 216.97 216.97 cigna hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 216.97 216.97 cigna pos "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 216.97 216.97 cigna epo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 675.67 675.67 cigna ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 675.67 675.67 cigna hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 675.67 675.67 cigna pos Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 675.67 675.67 cigna epo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 159.01 159.01 cigna ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 159.01 159.01 cigna hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 159.01 159.01 cigna pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 159.01 159.01 cigna epo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 8278.58 8278.58 cigna ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 8278.58 8278.58 cigna hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 8278.58 8278.58 cigna pos Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 8278.58 8278.58 cigna epo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 19270.59 19270.59 cigna ppo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 19270.59 19270.59 cigna hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 19270.59 19270.59 cigna pos hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 19270.59 19270.59 cigna epo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 122.6 122.6 cigna ppo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 122.6 122.6 cigna hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 122.6 122.6 cigna pos "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 122.6 122.6 cigna epo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 4972.53 4972.53 cigna ppo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 4972.53 4972.53 cigna hmo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 4972.53 4972.53 cigna pos vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 4972.53 4972.53 cigna epo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 2651.78 2651.78 cigna ppo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 2651.78 2651.78 cigna hmo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 2651.78 2651.78 cigna pos inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 2651.78 2651.78 cigna epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 21270.9 21270.9 cigna ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 21270.9 21270.9 cigna hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 21270.9 21270.9 cigna pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 21270.9 21270.9 cigna epo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 182.72 182.72 cigna ppo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 182.72 182.72 cigna hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 182.72 182.72 cigna pos Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 182.72 182.72 cigna epo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 19270.59 19270.59 cigna ppo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 19270.59 19270.59 cigna hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 19270.59 19270.59 cigna pos cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 19270.59 19270.59 cigna epo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 43.84 43.84 cigna ppo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 43.84 43.84 cigna hmo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 43.84 43.84 cigna pos Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 43.84 43.84 cigna epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 72.08 72.08 cigna ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 72.08 72.08 cigna hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 72.08 72.08 cigna pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 72.08 72.08 cigna epo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 562.74 562.74 cigna ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 562.74 562.74 cigna hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 562.74 562.74 cigna pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 562.74 562.74 cigna epo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 5002.28 5002.28 cigna ppo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 5002.28 5002.28 cigna hmo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 5002.28 5002.28 cigna pos morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 5002.28 5002.28 cigna epo "stomach, esophageal and duodenal procedures with mcc" ms-drg 326 288925.38 288925.38 28518.81 28518.81 166466.87 166466.87 138722.39 138722.39 I 288925.38 288925.38 cigna ppo "stomach, esophageal and duodenal procedures with mcc" ms-drg 326 288925.38 288925.38 28518.81 28518.81 166466.87 166466.87 138722.39 138722.39 I 288925.38 288925.38 cigna hmo "stomach, esophageal and duodenal procedures with mcc" ms-drg 326 288925.38 288925.38 28518.81 28518.81 166466.87 166466.87 138722.39 138722.39 I 288925.38 288925.38 cigna pos "stomach, esophageal and duodenal procedures with mcc" ms-drg 326 288925.38 288925.38 28518.81 28518.81 166466.87 166466.87 138722.39 138722.39 I 288925.38 288925.38 cigna epo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2210.37 2210.37 cigna ppo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2210.37 2210.37 cigna hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2210.37 2210.37 cigna pos Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2210.37 2210.37 cigna epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 29.94 29.94 cigna ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 29.94 29.94 cigna hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 29.94 29.94 cigna pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 29.94 29.94 cigna epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 83.22 83.22 cigna ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 83.22 83.22 cigna hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 83.22 83.22 cigna pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 83.22 83.22 cigna epo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna ppo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna hmo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna pos "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 384.91 384.91 cigna epo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1286.12 1286.12 cigna ppo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1286.12 1286.12 cigna hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1286.12 1286.12 cigna pos "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1286.12 1286.12 cigna epo "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 142.67 142.67 cigna ppo "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 142.67 142.67 cigna hmo "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 142.67 142.67 cigna pos "X-ray of pelvis, 1 or 2 views" cpt 72170 142.67 142.67 20.47 20.47 244.22 244.22 203.52 203.52 O 142.67 142.67 cigna epo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 4154.86 4154.86 cigna ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 4154.86 4154.86 cigna hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 4154.86 4154.86 cigna pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 4154.86 4154.86 cigna epo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 143.62 143.62 cigna ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 143.62 143.62 cigna hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 143.62 143.62 cigna pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 143.62 143.62 cigna epo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 26149.85 26149.85 cigna ppo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 26149.85 26149.85 cigna hmo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 26149.85 26149.85 cigna pos postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 26149.85 26149.85 cigna epo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 19270.59 19270.59 cigna ppo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 19270.59 19270.59 cigna hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 19270.59 19270.59 cigna pos ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 19270.59 19270.59 cigna epo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 5534.65 5534.65 cigna ppo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 5534.65 5534.65 cigna hmo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 5534.65 5534.65 cigna pos simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 5534.65 5534.65 cigna epo cefazolin sodium injection cpt J0690 9081.99 9081.99 1725.97 1725.97 18886.44 18886.44 15738.7 15738.7 E 1725.97 1725.97 cigna ppo cefazolin sodium injection cpt J0690 9081.99 9081.99 1725.97 1725.97 18886.44 18886.44 15738.7 15738.7 E 1725.97 1725.97 cigna hmo cefazolin sodium injection cpt J0690 9081.99 9081.99 1725.97 1725.97 18886.44 18886.44 15738.7 15738.7 E 1725.97 1725.97 cigna pos cefazolin sodium injection cpt J0690 9081.99 9081.99 1725.97 1725.97 18886.44 18886.44 15738.7 15738.7 E 1725.97 1725.97 cigna epo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4844.02 4844.02 cigna ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4844.02 4844.02 cigna hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4844.02 4844.02 cigna pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4844.02 4844.02 cigna epo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1591.1 1591.1 cigna ppo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1591.1 1591.1 cigna hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1591.1 1591.1 cigna pos CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1591.1 1591.1 cigna epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 2651.78 2651.78 cigna ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 2651.78 2651.78 cigna hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 2651.78 2651.78 cigna pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 2651.78 2651.78 cigna epo Ultrasound study of arteries of both legs at rest and exercise cpt 93924 283.11 283.11 121.58 121.58 484.63 484.63 403.86 403.86 O 283.11 283.11 cigna ppo Ultrasound study of arteries of both legs at rest and exercise cpt 93924 283.11 283.11 121.58 121.58 484.63 484.63 403.86 403.86 O 283.11 283.11 cigna hmo Ultrasound study of arteries of both legs at rest and exercise cpt 93924 283.11 283.11 121.58 121.58 484.63 484.63 403.86 403.86 O 283.11 283.11 cigna pos Ultrasound study of arteries of both legs at rest and exercise cpt 93924 283.11 283.11 121.58 121.58 484.63 484.63 403.86 403.86 O 283.11 283.11 cigna epo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 3539.01 3539.01 cigna ppo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 3539.01 3539.01 cigna hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 3539.01 3539.01 cigna pos inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 3539.01 3539.01 cigna epo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1039.54 1039.54 cigna ppo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1039.54 1039.54 cigna hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1039.54 1039.54 cigna pos "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1039.54 1039.54 cigna epo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 11447.12 11447.12 cigna ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 11447.12 11447.12 cigna hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 11447.12 11447.12 cigna pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 11447.12 11447.12 cigna epo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 430.6 430.6 cigna ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 430.6 430.6 cigna hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 430.6 430.6 cigna pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 430.6 430.6 cigna epo Dilation of stomach outlet using an endoscope cpt 43245 3539.01 3539.01 3539.01 3539.01 6316.46 6316.46 5263.72 5263.72 O 3539.01 3539.01 cigna ppo Dilation of stomach outlet using an endoscope cpt 43245 3539.01 3539.01 3539.01 3539.01 6316.46 6316.46 5263.72 5263.72 O 3539.01 3539.01 cigna hmo Dilation of stomach outlet using an endoscope cpt 43245 3539.01 3539.01 3539.01 3539.01 6316.46 6316.46 5263.72 5263.72 O 3539.01 3539.01 cigna pos Dilation of stomach outlet using an endoscope cpt 43245 3539.01 3539.01 3539.01 3539.01 6316.46 6316.46 5263.72 5263.72 O 3539.01 3539.01 cigna epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 348.5 348.5 cigna ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 348.5 348.5 cigna hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 348.5 348.5 cigna pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 348.5 348.5 cigna epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 7694.58 7694.58 cigna ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 7694.58 7694.58 cigna hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 7694.58 7694.58 cigna pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 7694.58 7694.58 cigna epo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 50054.52 50054.52 cigna ppo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 50054.52 50054.52 cigna hmo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 50054.52 50054.52 cigna pos cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 50054.52 50054.52 cigna epo inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 21270.9 21270.9 cigna ppo inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 21270.9 21270.9 cigna hmo inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 21270.9 21270.9 cigna pos inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 21270.9 21270.9 cigna epo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1867.64 1867.64 cigna ppo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1867.64 1867.64 cigna hmo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1867.64 1867.64 cigna pos ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 1867.64 1867.64 cigna epo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 348.55 348.55 cigna ppo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 348.55 348.55 cigna hmo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 348.55 348.55 cigna pos Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 348.55 348.55 cigna epo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1337.49 1337.49 cigna ppo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1337.49 1337.49 cigna hmo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1337.49 1337.49 cigna pos ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1337.49 1337.49 cigna epo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 2876.37 2876.37 cigna ppo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 2876.37 2876.37 cigna hmo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 2876.37 2876.37 cigna pos prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 2876.37 2876.37 cigna epo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 230.05 230.05 cigna ppo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 230.05 230.05 cigna hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 230.05 230.05 cigna pos "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 230.05 230.05 cigna epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1186.67 1186.67 cigna ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1186.67 1186.67 cigna hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1186.67 1186.67 cigna pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1186.67 1186.67 cigna epo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 3539.01 3539.01 cigna ppo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 3539.01 3539.01 cigna hmo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 3539.01 3539.01 cigna pos meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 3539.01 3539.01 cigna epo prematurity without major problems ms-drg 792 29733.1 29733.1 7711.45 7711.45 12370.37 12370.37 10308.64 10308.64 I 29733.1 29733.1 cigna ppo prematurity without major problems ms-drg 792 29733.1 29733.1 7711.45 7711.45 12370.37 12370.37 10308.64 10308.64 I 29733.1 29733.1 cigna hmo prematurity without major problems ms-drg 792 29733.1 29733.1 7711.45 7711.45 12370.37 12370.37 10308.64 10308.64 I 29733.1 29733.1 cigna pos prematurity without major problems ms-drg 792 29733.1 29733.1 7711.45 7711.45 12370.37 12370.37 10308.64 10308.64 I 29733.1 29733.1 cigna epo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 52.49 52.49 cigna ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 52.49 52.49 cigna hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 52.49 52.49 cigna pos "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 52.49 52.49 cigna epo succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 21270.9 21270.9 cigna ppo succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 21270.9 21270.9 cigna hmo succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 21270.9 21270.9 cigna pos succinycholine chloride inj cpt J0330 21270.9 21270.9 1218.97 1218.97 29115.38 29115.38 24262.82 24262.82 E 21270.9 21270.9 cigna epo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4844.02 4844.02 cigna ppo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4844.02 4844.02 cigna hmo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4844.02 4844.02 cigna pos leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 4844.02 4844.02 cigna epo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1117.56 1117.56 cigna ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1117.56 1117.56 cigna hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1117.56 1117.56 cigna pos CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1117.56 1117.56 cigna epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 35.44 35.44 cigna ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 35.44 35.44 cigna hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 35.44 35.44 cigna pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 35.44 35.44 cigna epo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 622.98 622.98 cigna ppo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 622.98 622.98 cigna hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 622.98 622.98 cigna pos "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 622.98 622.98 cigna epo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 55.41 55.41 cigna ppo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 55.41 55.41 cigna hmo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 55.41 55.41 cigna pos Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 55.41 55.41 cigna epo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 11266.74 11266.74 cigna ppo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 11266.74 11266.74 cigna hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 11266.74 11266.74 cigna pos acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 11266.74 11266.74 cigna epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2136.3 2136.3 cigna ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2136.3 2136.3 cigna hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2136.3 2136.3 cigna pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2136.3 2136.3 cigna epo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna pos Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna epo piperacillin/tazobactam cpt J2543 21270.9 21270.9 812.44 812.44 12102.08 12102.08 10085.07 10085.07 E 21270.9 21270.9 cigna ppo piperacillin/tazobactam cpt J2543 21270.9 21270.9 812.44 812.44 12102.08 12102.08 10085.07 10085.07 E 21270.9 21270.9 cigna hmo piperacillin/tazobactam cpt J2543 21270.9 21270.9 812.44 812.44 12102.08 12102.08 10085.07 10085.07 E 21270.9 21270.9 cigna pos piperacillin/tazobactam cpt J2543 21270.9 21270.9 812.44 812.44 12102.08 12102.08 10085.07 10085.07 E 21270.9 21270.9 cigna epo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 21270.9 21270.9 cigna ppo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 21270.9 21270.9 cigna hmo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 21270.9 21270.9 cigna pos acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 21270.9 21270.9 cigna epo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 1379.36 1379.36 cigna ppo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 1379.36 1379.36 cigna hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 1379.36 1379.36 cigna pos Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 1379.36 1379.36 cigna epo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 38.29 38.29 cigna ppo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 38.29 38.29 cigna hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 38.29 38.29 cigna pos Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 38.29 38.29 cigna epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 55.95 55.95 cigna ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 55.95 55.95 cigna hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 55.95 55.95 cigna pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 55.95 55.95 cigna epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2136.3 2136.3 cigna ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2136.3 2136.3 cigna hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2136.3 2136.3 cigna pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2136.3 2136.3 cigna epo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 64.66 64.66 cigna ppo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 64.66 64.66 cigna hmo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 64.66 64.66 cigna pos Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 64.66 64.66 cigna epo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 54.86 54.86 cigna ppo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 54.86 54.86 cigna hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 54.86 54.86 cigna pos Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 54.86 54.86 cigna epo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 3539.01 3539.01 cigna ppo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 3539.01 3539.01 cigna hmo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 3539.01 3539.01 cigna pos mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 3539.01 3539.01 cigna epo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 17825.76 17825.76 cigna ppo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 17825.76 17825.76 cigna hmo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 17825.76 17825.76 cigna pos laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 17825.76 17825.76 cigna epo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 18810.66 18810.66 cigna ppo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 18810.66 18810.66 cigna hmo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 18810.66 18810.66 cigna pos hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 18810.66 18810.66 cigna epo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 3225.5 3225.5 cigna ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 3225.5 3225.5 cigna hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 3225.5 3225.5 cigna pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 3225.5 3225.5 cigna epo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 19270.59 19270.59 cigna ppo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 19270.59 19270.59 cigna hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 19270.59 19270.59 cigna pos fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 19270.59 19270.59 cigna epo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 611.54 611.54 cigna ppo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 611.54 611.54 cigna hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 611.54 611.54 cigna pos "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 611.54 611.54 cigna epo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 115.02 115.02 cigna ppo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 115.02 115.02 cigna hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 115.02 115.02 cigna pos "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 115.02 115.02 cigna epo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 42.57 42.57 cigna ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 42.57 42.57 cigna hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 42.57 42.57 cigna pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 42.57 42.57 cigna epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 155.22 155.22 cigna ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 155.22 155.22 cigna hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 155.22 155.22 cigna pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 155.22 155.22 cigna epo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 18.13 18.13 cigna ppo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 18.13 18.13 cigna hmo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 18.13 18.13 cigna pos Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 18.13 18.13 cigna epo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 133.75 133.75 24.84 24.84 228.96 228.96 190.8 190.8 E 133.75 133.75 cigna ppo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 133.75 133.75 24.84 24.84 228.96 228.96 190.8 190.8 E 133.75 133.75 cigna hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 133.75 133.75 24.84 24.84 228.96 228.96 190.8 190.8 E 133.75 133.75 cigna pos "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 133.75 133.75 24.84 24.84 228.96 228.96 190.8 190.8 E 133.75 133.75 cigna epo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 21270.9 21270.9 cigna ppo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 21270.9 21270.9 cigna hmo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 21270.9 21270.9 cigna pos fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 21270.9 21270.9 cigna epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 75.79 75.79 cigna ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 75.79 75.79 cigna hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 75.79 75.79 cigna pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 75.79 75.79 cigna epo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 447.32 447.32 cigna ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 447.32 447.32 cigna hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 447.32 447.32 cigna pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 447.32 447.32 cigna epo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 278.65 278.65 cigna ppo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 278.65 278.65 cigna hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 278.65 278.65 cigna pos Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 278.65 278.65 cigna epo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4844.02 4844.02 cigna ppo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4844.02 4844.02 cigna hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4844.02 4844.02 cigna pos fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4844.02 4844.02 cigna epo "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 852.29 852.29 cigna ppo "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 852.29 852.29 cigna hmo "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 852.29 852.29 cigna pos "Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report" cpt 93350 852.29 852.29 389.69 389.69 1458.98 1458.98 1215.82 1215.82 O 852.29 852.29 cigna epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 79.51 79.51 cigna ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 79.51 79.51 cigna hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 79.51 79.51 cigna pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 79.51 79.51 cigna epo kidney and ureter procedures for non-neoplasm without cc/mcc ms-drg 661 24215.64 24215.64 5983.11 5983.11 43738.31 43738.31 36448.59 36448.59 I 24215.64 24215.64 cigna ppo kidney and ureter procedures for non-neoplasm without cc/mcc ms-drg 661 24215.64 24215.64 5983.11 5983.11 43738.31 43738.31 36448.59 36448.59 I 24215.64 24215.64 cigna hmo kidney and ureter procedures for non-neoplasm without cc/mcc ms-drg 661 24215.64 24215.64 5983.11 5983.11 43738.31 43738.31 36448.59 36448.59 I 24215.64 24215.64 cigna pos kidney and ureter procedures for non-neoplasm without cc/mcc ms-drg 661 24215.64 24215.64 5983.11 5983.11 43738.31 43738.31 36448.59 36448.59 I 24215.64 24215.64 cigna epo Removal of appendix using an endoscope cpt 44970 21270.9 21270.9 4222.64 4222.64 35680.25 35680.25 29733.54 29733.54 E 21270.9 21270.9 cigna ppo Removal of appendix using an endoscope cpt 44970 21270.9 21270.9 4222.64 4222.64 35680.25 35680.25 29733.54 29733.54 E 21270.9 21270.9 cigna hmo Removal of appendix using an endoscope cpt 44970 21270.9 21270.9 4222.64 4222.64 35680.25 35680.25 29733.54 29733.54 E 21270.9 21270.9 cigna pos Removal of appendix using an endoscope cpt 44970 21270.9 21270.9 4222.64 4222.64 35680.25 35680.25 29733.54 29733.54 E 21270.9 21270.9 cigna epo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 20.81 20.81 cigna ppo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 20.81 20.81 cigna hmo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 20.81 20.81 cigna pos "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 20.81 20.81 cigna epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 69.1 69.1 cigna ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 69.1 69.1 cigna hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 69.1 69.1 cigna pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 69.1 69.1 cigna epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 187.86 187.86 cigna ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 187.86 187.86 cigna hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 187.86 187.86 cigna pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 187.86 187.86 cigna epo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 8278.58 8278.58 cigna ppo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 8278.58 8278.58 cigna hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 8278.58 8278.58 cigna pos inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 8278.58 8278.58 cigna epo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 49.79 49.79 cigna ppo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 49.79 49.79 cigna hmo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 49.79 49.79 cigna pos "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 49.79 49.79 cigna epo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 8278.58 8278.58 cigna ppo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 8278.58 8278.58 cigna hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 8278.58 8278.58 cigna pos hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 8278.58 8278.58 cigna epo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 52.76 52.76 cigna ppo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 52.76 52.76 cigna hmo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 52.76 52.76 cigna pos Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 52.76 52.76 cigna epo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 66.95 66.95 cigna ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 66.95 66.95 cigna hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 66.95 66.95 cigna pos Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 66.95 66.95 cigna epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.48 11.48 cigna ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.48 11.48 cigna hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.48 11.48 cigna pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.48 11.48 cigna epo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 53.5 53.5 cigna ppo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 53.5 53.5 cigna hmo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 53.5 53.5 cigna pos Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 53.5 53.5 cigna epo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 8071.15 8071.15 cigna ppo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 8071.15 8071.15 cigna hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 8071.15 8071.15 cigna pos Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 8071.15 8071.15 cigna epo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 45.85 45.85 cigna ppo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 45.85 45.85 cigna hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 45.85 45.85 cigna pos Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 45.85 45.85 cigna epo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 8767.32 8767.32 cigna ppo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 8767.32 8767.32 cigna hmo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 8767.32 8767.32 cigna pos poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 8767.32 8767.32 cigna epo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 159.02 159.02 cigna ppo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 159.02 159.02 cigna hmo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 159.02 159.02 cigna pos "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 159.02 159.02 cigna epo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 208.8 208.8 cigna ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 208.8 208.8 cigna hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 208.8 208.8 cigna pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 208.8 208.8 cigna epo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 24.52 24.52 cigna ppo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 24.52 24.52 cigna hmo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 24.52 24.52 cigna pos "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 24.52 24.52 cigna epo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1590.91 1590.91 cigna ppo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1590.91 1590.91 cigna hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1590.91 1590.91 cigna pos "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1590.91 1590.91 cigna epo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 8.69 8.69 cigna ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 8.69 8.69 cigna hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 8.69 8.69 cigna pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 8.69 8.69 cigna epo "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 187.99 187.99 cigna ppo "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 187.99 187.99 cigna hmo "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 187.99 187.99 cigna pos "Pathology examination of tissue using a microscope, moderately high complexity" cpt 88307 187.99 187.99 60.63 60.63 321.82 321.82 268.18 268.18 O 187.99 187.99 cigna epo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna ppo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna pos palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna epo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 25.26 25.26 cigna ppo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 25.26 25.26 cigna hmo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 25.26 25.26 cigna pos Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 25.26 25.26 cigna epo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 115.92 115.92 cigna ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 115.92 115.92 cigna hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 115.92 115.92 cigna pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 115.92 115.92 cigna epo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 48.76 48.76 cigna ppo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 48.76 48.76 cigna hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 48.76 48.76 cigna pos Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 48.76 48.76 cigna epo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 78.7 78.7 cigna ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 78.7 78.7 cigna hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 78.7 78.7 cigna pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 78.7 78.7 cigna epo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 46.51 46.51 cigna ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 46.51 46.51 cigna hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 46.51 46.51 cigna pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 46.51 46.51 cigna epo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 95.74 95.74 cigna epo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1725.97 1725.97 cigna ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1725.97 1725.97 cigna hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1725.97 1725.97 cigna pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1725.97 1725.97 cigna epo Lactate dehydrogenase (enzyme) level cpt 83615 71.33 71.33 5.37 5.37 122.11 122.11 101.76 101.76 E 71.33 71.33 cigna ppo Lactate dehydrogenase (enzyme) level cpt 83615 71.33 71.33 5.37 5.37 122.11 122.11 101.76 101.76 E 71.33 71.33 cigna hmo Lactate dehydrogenase (enzyme) level cpt 83615 71.33 71.33 5.37 5.37 122.11 122.11 101.76 101.76 E 71.33 71.33 cigna pos Lactate dehydrogenase (enzyme) level cpt 83615 71.33 71.33 5.37 5.37 122.11 122.11 101.76 101.76 E 71.33 71.33 cigna epo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna pos dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4844.02 4844.02 cigna epo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 53.5 53.5 cigna ppo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 53.5 53.5 cigna hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 53.5 53.5 cigna pos Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 53.5 53.5 cigna epo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4844.02 4844.02 cigna ppo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4844.02 4844.02 cigna hmo oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4844.02 4844.02 cigna pos oxaliplatin cpt J9263 5479.02 5479.02 938.77 938.77 8823.35 8823.35 7352.79 7352.79 O 4844.02 4844.02 cigna epo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 37239.8 37239.8 cigna ppo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 37239.8 37239.8 cigna hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 37239.8 37239.8 cigna pos Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 37239.8 37239.8 cigna epo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 240.04 240.04 cigna ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 240.04 240.04 cigna hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 240.04 240.04 cigna pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 240.04 240.04 cigna epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 295.84 295.84 cigna ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 295.84 295.84 cigna hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 295.84 295.84 cigna pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 295.84 295.84 cigna epo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 3539.01 3539.01 cigna ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 3539.01 3539.01 cigna hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 3539.01 3539.01 cigna pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 3539.01 3539.01 cigna epo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 19270.59 19270.59 cigna ppo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 19270.59 19270.59 cigna hmo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 19270.59 19270.59 cigna pos succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 19270.59 19270.59 cigna epo Liver function blood test panel cpt 80076 135.53 135.53 7.27 7.27 232.01 232.01 193.34 193.34 E 135.53 135.53 cigna ppo Liver function blood test panel cpt 80076 135.53 135.53 7.27 7.27 232.01 232.01 193.34 193.34 E 135.53 135.53 cigna hmo Liver function blood test panel cpt 80076 135.53 135.53 7.27 7.27 232.01 232.01 193.34 193.34 E 135.53 135.53 cigna pos Liver function blood test panel cpt 80076 135.53 135.53 7.27 7.27 232.01 232.01 193.34 193.34 E 135.53 135.53 cigna epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1623.33 1623.33 cigna ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1623.33 1623.33 cigna hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1623.33 1623.33 cigna pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1623.33 1623.33 cigna epo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 207.31 207.31 cigna ppo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 207.31 207.31 cigna hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 207.31 207.31 cigna pos "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 207.31 207.31 cigna epo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 1130.86 1130.86 cigna ppo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 1130.86 1130.86 cigna hmo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 1130.86 1130.86 cigna pos "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 1130.86 1130.86 cigna epo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 69.83 69.83 cigna ppo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 69.83 69.83 cigna hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 69.83 69.83 cigna pos Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 69.83 69.83 cigna epo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 192.96 192.96 cigna ppo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 192.96 192.96 cigna hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 192.96 192.96 cigna pos Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 192.96 192.96 cigna epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 77.2 77.2 cigna ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 77.2 77.2 cigna hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 77.2 77.2 cigna pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 77.2 77.2 cigna epo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 19270.59 19270.59 cigna ppo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 19270.59 19270.59 cigna hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 19270.59 19270.59 cigna pos ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 19270.59 19270.59 cigna epo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 111.09 111.09 cigna ppo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 111.09 111.09 cigna hmo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 111.09 111.09 cigna pos "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 111.09 111.09 cigna epo Kidney function blood test panel cpt 80069 180.41 180.41 7.72 7.72 308.83 308.83 257.36 257.36 E 180.41 180.41 cigna ppo Kidney function blood test panel cpt 80069 180.41 180.41 7.72 7.72 308.83 308.83 257.36 257.36 E 180.41 180.41 cigna hmo Kidney function blood test panel cpt 80069 180.41 180.41 7.72 7.72 308.83 308.83 257.36 257.36 E 180.41 180.41 cigna pos Kidney function blood test panel cpt 80069 180.41 180.41 7.72 7.72 308.83 308.83 257.36 257.36 E 180.41 180.41 cigna epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1964.01 1964.01 cigna ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1964.01 1964.01 cigna hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1964.01 1964.01 cigna pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1964.01 1964.01 cigna epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 70.89 70.89 cigna ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 70.89 70.89 cigna hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 70.89 70.89 cigna pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 70.89 70.89 cigna epo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 264.53 264.53 cigna ppo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 264.53 264.53 cigna hmo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 264.53 264.53 cigna pos "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 264.53 264.53 cigna epo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 10844.92 10844.92 cigna ppo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 10844.92 10844.92 cigna hmo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 10844.92 10844.92 cigna pos dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 10844.92 10844.92 cigna epo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna ppo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna pos Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna epo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4844.02 4844.02 cigna ppo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4844.02 4844.02 cigna hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4844.02 4844.02 cigna pos fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4844.02 4844.02 cigna epo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna ppo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna hmo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna pos "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 333.26 333.26 cigna ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 333.26 333.26 cigna hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 333.26 333.26 cigna pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 333.26 333.26 cigna epo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 4154.86 4154.86 cigna ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 4154.86 4154.86 cigna hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 4154.86 4154.86 cigna pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 4154.86 4154.86 cigna epo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 5002.28 5002.28 cigna ppo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 5002.28 5002.28 cigna hmo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 5002.28 5002.28 cigna pos ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 5002.28 5002.28 cigna epo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 52.44 52.44 cigna ppo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 52.44 52.44 cigna hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 52.44 52.44 cigna pos "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 52.44 52.44 cigna epo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna ppo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna pos Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 608.56 608.56 cigna epo "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 19270.59 19270.59 cigna ppo "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 19270.59 19270.59 cigna hmo "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 19270.59 19270.59 cigna pos "catheter, occlusion" cpt C2628 19270.59 19270.59 215.94 215.94 36433.46 36433.46 30361.22 30361.22 O 19270.59 19270.59 cigna epo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 57.51 57.51 cigna ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 57.51 57.51 cigna hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 57.51 57.51 cigna pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 57.51 57.51 cigna epo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna ppo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna hmo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna pos "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 207.31 207.31 cigna epo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 181.15 181.15 cigna ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 181.15 181.15 cigna hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 181.15 181.15 cigna pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 181.15 181.15 cigna epo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1644.68 1644.68 cigna ppo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1644.68 1644.68 cigna hmo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1644.68 1644.68 cigna pos CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1644.68 1644.68 cigna epo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 26.82 26.82 cigna ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 26.82 26.82 cigna hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 26.82 26.82 cigna pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 26.82 26.82 cigna epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 44.13 44.13 cigna ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 44.13 44.13 cigna hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 44.13 44.13 cigna pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 44.13 44.13 cigna epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 44.13 44.13 cigna ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 44.13 44.13 cigna hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 44.13 44.13 cigna pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 44.13 44.13 cigna epo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 46.39 46.39 cigna ppo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 46.39 46.39 cigna hmo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 46.39 46.39 cigna pos "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 46.39 46.39 cigna epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.77 67.77 cigna epo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 19286.76 19286.76 cigna ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 19286.76 19286.76 cigna hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 19286.76 19286.76 cigna pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 19286.76 19286.76 cigna epo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 2005.98 2005.98 cigna ppo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 2005.98 2005.98 cigna hmo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 2005.98 2005.98 cigna pos "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 2005.98 2005.98 cigna epo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 418.93 418.93 cigna ppo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 418.93 418.93 cigna hmo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 418.93 418.93 cigna pos orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 418.93 418.93 cigna epo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 400.09 400.09 cigna ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 400.09 400.09 cigna hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 400.09 400.09 cigna pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 400.09 400.09 cigna epo Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 19270.59 19270.59 cigna ppo Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 19270.59 19270.59 cigna hmo Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 19270.59 19270.59 cigna pos Abdominal removal of uterus (250 grams or less) with removal of tubes and/or ovaries using an endoscope cpt 58571 19270.59 19270.59 215.94 215.94 35736.19 35736.19 29780.16 29780.16 O 19270.59 19270.59 cigna epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 57.22 57.22 cigna ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 57.22 57.22 cigna hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 57.22 57.22 cigna pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 57.22 57.22 cigna epo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 1130.86 1130.86 cigna ppo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 1130.86 1130.86 cigna hmo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 1130.86 1130.86 cigna pos Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 1130.86 1130.86 cigna epo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 4154.86 4154.86 cigna ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 4154.86 4154.86 cigna hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 4154.86 4154.86 cigna pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 4154.86 4154.86 cigna epo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 188.58 188.58 cigna ppo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 188.58 188.58 cigna hmo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 188.58 188.58 cigna pos "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 188.58 188.58 cigna epo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 912.6 912.6 cigna ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 912.6 912.6 cigna hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 912.6 912.6 cigna pos Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 912.6 912.6 cigna epo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 33.14 33.14 cigna epo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 19270.59 19270.59 cigna ppo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 19270.59 19270.59 cigna hmo metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 19270.59 19270.59 cigna pos metoclopramide hcl injection cpt J2765 19270.59 19270.59 1190.8 1190.8 19104.05 19104.05 15920.04 15920.04 O 19270.59 19270.59 cigna epo endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 19059.25 19059.25 cigna ppo endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 19059.25 19059.25 cigna hmo endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 19059.25 19059.25 cigna pos endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 19059.25 19059.25 cigna epo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 917.66 917.66 cigna ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 917.66 917.66 cigna hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 917.66 917.66 cigna pos "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 917.66 917.66 cigna epo metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 21270.9 21270.9 cigna ppo metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 21270.9 21270.9 cigna hmo metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 21270.9 21270.9 cigna pos metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 21270.9 21270.9 cigna epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4844.02 4844.02 cigna ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4844.02 4844.02 cigna hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4844.02 4844.02 cigna pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4844.02 4844.02 cigna epo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 783.67 783.67 cigna ppo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 783.67 783.67 cigna hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 783.67 783.67 cigna pos "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 783.67 783.67 cigna epo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 25.26 25.26 cigna ppo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 25.26 25.26 cigna hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 25.26 25.26 cigna pos Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 25.26 25.26 cigna epo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna pos inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 4844.02 4844.02 cigna epo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 150.1 150.1 cigna ppo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 150.1 150.1 cigna hmo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 150.1 150.1 cigna pos "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 150.1 150.1 cigna epo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2876.37 2876.37 cigna ppo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2876.37 2876.37 cigna hmo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2876.37 2876.37 cigna pos diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2876.37 2876.37 cigna epo MRI scan brain cpt 70551 1815.29 1815.29 124.83 124.83 3107.5 3107.5 2589.58 2589.58 E 1815.29 1815.29 cigna ppo MRI scan brain cpt 70551 1815.29 1815.29 124.83 124.83 3107.5 3107.5 2589.58 2589.58 E 1815.29 1815.29 cigna hmo MRI scan brain cpt 70551 1815.29 1815.29 124.83 124.83 3107.5 3107.5 2589.58 2589.58 E 1815.29 1815.29 cigna pos MRI scan brain cpt 70551 1815.29 1815.29 124.83 124.83 3107.5 3107.5 2589.58 2589.58 E 1815.29 1815.29 cigna epo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3225.5 3225.5 cigna ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3225.5 3225.5 cigna hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3225.5 3225.5 cigna pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3225.5 3225.5 cigna epo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 19270.59 19270.59 cigna ppo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 19270.59 19270.59 cigna hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 19270.59 19270.59 cigna pos ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 19270.59 19270.59 cigna epo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 92.95 92.95 cigna ppo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 92.95 92.95 cigna hmo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 92.95 92.95 cigna pos Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 92.95 92.95 cigna epo "other injury, poisoning and toxic effect diagnoses without mcc" ms-drg 923 27632.25 27632.25 3062.32 3062.32 22082.47 22082.47 18402.06 18402.06 I 27632.25 27632.25 cigna ppo "other injury, poisoning and toxic effect diagnoses without mcc" ms-drg 923 27632.25 27632.25 3062.32 3062.32 22082.47 22082.47 18402.06 18402.06 I 27632.25 27632.25 cigna hmo "other injury, poisoning and toxic effect diagnoses without mcc" ms-drg 923 27632.25 27632.25 3062.32 3062.32 22082.47 22082.47 18402.06 18402.06 I 27632.25 27632.25 cigna pos "other injury, poisoning and toxic effect diagnoses without mcc" ms-drg 923 27632.25 27632.25 3062.32 3062.32 22082.47 22082.47 18402.06 18402.06 I 27632.25 27632.25 cigna epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 3225.5 3225.5 cigna ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 3225.5 3225.5 cigna hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 3225.5 3225.5 cigna pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 3225.5 3225.5 cigna epo ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 21270.9 21270.9 cigna ppo ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 21270.9 21270.9 cigna hmo ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 21270.9 21270.9 cigna pos ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 21270.9 21270.9 cigna epo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 45.33 45.33 cigna ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 45.33 45.33 cigna hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 45.33 45.33 cigna pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 45.33 45.33 cigna epo other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 29514.43 29514.43 cigna ppo other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 29514.43 29514.43 cigna hmo other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 29514.43 29514.43 cigna pos other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 29514.43 29514.43 cigna epo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 7986.58 7986.58 cigna ppo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 7986.58 7986.58 cigna hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 7986.58 7986.58 cigna pos "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 7986.58 7986.58 cigna epo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 696.54 696.54 cigna ppo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 696.54 696.54 cigna hmo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 696.54 696.54 cigna pos Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 696.54 696.54 cigna epo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.35 10.35 cigna medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.35 10.35 cigna medicare advantage hmo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 13.27 13.27 cigna medicare advantage pos "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 13.27 13.27 cigna medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 39.09 39.09 cigna medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 39.09 39.09 cigna medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.61 7.61 cigna medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.61 7.61 cigna medicare advantage hmo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 4.92 4.92 cigna medicare advantage pos "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 4.92 4.92 cigna medicare advantage hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.2 2.2 cigna medicare advantage pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.2 2.2 cigna medicare advantage hmo other musculoskeletal system and connective tissue o.r. procedures without cc/mcc ms-drg 517 9446.71 9446.71 4008.64 4008.64 36975.23 36975.23 30812.69 30812.69 I 4008.64 4008.64 healthchoice hmo other musculoskeletal system and connective tissue o.r. procedures without cc/mcc ms-drg 517 9446.71 9446.71 4008.64 4008.64 36975.23 36975.23 30812.69 30812.69 I 4008.64 4008.64 healthchoice epo other musculoskeletal system and connective tissue o.r. procedures without cc/mcc ms-drg 517 9446.71 9446.71 4008.64 4008.64 36975.23 36975.23 30812.69 30812.69 I 4008.64 4008.64 healthchoice pos other musculoskeletal system and connective tissue o.r. procedures without cc/mcc ms-drg 517 9446.71 9446.71 4008.64 4008.64 36975.23 36975.23 30812.69 30812.69 I 4008.64 4008.64 healthchoice hmo other musculoskeletal system and connective tissue o.r. procedures without cc/mcc ms-drg 517 9446.71 9446.71 4008.64 4008.64 36975.23 36975.23 30812.69 30812.69 I 4008.64 4008.64 healthchoice ppo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1648.63 1648.63 healthchoice hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1648.63 1648.63 healthchoice epo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1648.63 1648.63 healthchoice pos Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1648.63 1648.63 healthchoice hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 1648.63 1648.63 healthchoice ppo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5252.68 5252.68 healthchoice hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5252.68 5252.68 healthchoice epo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5252.68 5252.68 healthchoice pos Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5252.68 5252.68 healthchoice hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 5252.68 5252.68 healthchoice ppo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4390.96 4390.96 healthchoice hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4390.96 4390.96 healthchoice epo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4390.96 4390.96 healthchoice pos Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4390.96 4390.96 healthchoice hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4390.96 4390.96 healthchoice ppo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 28.76 28.76 healthchoice hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 28.76 28.76 healthchoice epo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 28.76 28.76 healthchoice pos Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 28.76 28.76 healthchoice hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 28.76 28.76 healthchoice ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 432.25 432.25 healthchoice hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 432.25 432.25 healthchoice epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 432.25 432.25 healthchoice pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 432.25 432.25 healthchoice hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 432.25 432.25 healthchoice ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 32.23 32.23 healthchoice hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 32.23 32.23 healthchoice epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 32.23 32.23 healthchoice pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 32.23 32.23 healthchoice hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 32.23 32.23 healthchoice ppo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 22.42 22.42 healthchoice hmo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 22.42 22.42 healthchoice epo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 22.42 22.42 healthchoice pos General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 22.42 22.42 healthchoice hmo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 22.42 22.42 healthchoice ppo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 5591.9 5591.9 healthchoice hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 5591.9 5591.9 healthchoice epo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 5591.9 5591.9 healthchoice pos f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 5591.9 5591.9 healthchoice hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 5591.9 5591.9 healthchoice ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 859.66 859.66 healthchoice hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 859.66 859.66 healthchoice epo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 859.66 859.66 healthchoice pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 859.66 859.66 healthchoice hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 859.66 859.66 healthchoice ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 40.85 40.85 healthchoice hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 40.85 40.85 healthchoice epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 40.85 40.85 healthchoice pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 40.85 40.85 healthchoice hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 40.85 40.85 healthchoice ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 49.3 49.3 healthchoice hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 49.3 49.3 healthchoice epo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 49.3 49.3 healthchoice pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 49.3 49.3 healthchoice hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 49.3 49.3 healthchoice ppo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 38.6 38.6 healthchoice hmo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 38.6 38.6 healthchoice epo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 38.6 38.6 healthchoice pos Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 38.6 38.6 healthchoice hmo Vitamin B-6 level cpt 84207 126.88 126.88 21.64 21.64 145.01 145.01 120.84 120.84 O 38.6 38.6 healthchoice ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 33.76 33.76 healthchoice hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 33.76 33.76 healthchoice epo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 33.76 33.76 healthchoice pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 33.76 33.76 healthchoice hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 33.76 33.76 healthchoice ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 26.28 26.28 healthchoice hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 26.28 26.28 healthchoice epo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 26.28 26.28 healthchoice pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 26.28 26.28 healthchoice hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 26.28 26.28 healthchoice ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 20.86 20.86 healthchoice hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 20.86 20.86 healthchoice epo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 20.86 20.86 healthchoice pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 20.86 20.86 healthchoice hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 20.86 20.86 healthchoice ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 52.35 52.35 healthchoice hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 52.35 52.35 healthchoice epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 52.35 52.35 healthchoice pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 52.35 52.35 healthchoice hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 52.35 52.35 healthchoice ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 18.85 18.85 healthchoice hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 18.85 18.85 healthchoice epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 18.85 18.85 healthchoice pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 18.85 18.85 healthchoice hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 18.85 18.85 healthchoice ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 13.41 13.41 healthchoice hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 13.41 13.41 healthchoice epo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 13.41 13.41 healthchoice pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 13.41 13.41 healthchoice hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 13.41 13.41 healthchoice ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 11.3 11.3 healthchoice hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 11.3 11.3 healthchoice epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 11.3 11.3 healthchoice pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 11.3 11.3 healthchoice hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 11.3 11.3 healthchoice ppo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 56.49 56.49 healthchoice hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 56.49 56.49 healthchoice epo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 56.49 56.49 healthchoice pos "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 56.49 56.49 healthchoice hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 56.49 56.49 healthchoice ppo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 2320.4 2320.4 healthchoice hmo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 2320.4 2320.4 healthchoice epo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 2320.4 2320.4 healthchoice pos "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 2320.4 2320.4 healthchoice hmo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 2320.4 2320.4 healthchoice ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 5.72 5.72 healthchoice hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 5.72 5.72 healthchoice epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 5.72 5.72 healthchoice pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 5.72 5.72 healthchoice hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 5.72 5.72 healthchoice ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 3.73 3.73 healthchoice hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 3.73 3.73 healthchoice epo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 3.73 3.73 healthchoice pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 3.73 3.73 healthchoice hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 3.73 3.73 healthchoice ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 859.66 859.66 healthchoice hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 859.66 859.66 healthchoice epo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 859.66 859.66 healthchoice pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 859.66 859.66 healthchoice hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 859.66 859.66 healthchoice ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 6.35 6.35 healthchoice hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 6.35 6.35 healthchoice epo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 6.35 6.35 healthchoice pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 6.35 6.35 healthchoice hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 6.35 6.35 healthchoice ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 588.45 588.45 healthchoice hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 588.45 588.45 healthchoice epo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 588.45 588.45 healthchoice pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 588.45 588.45 healthchoice hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 588.45 588.45 healthchoice ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 6.96 6.96 healthchoice hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 6.96 6.96 healthchoice epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 6.96 6.96 healthchoice pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 6.96 6.96 healthchoice hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 6.96 6.96 healthchoice ppo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 33.71 33.71 humana pos Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 33.71 33.71 humana ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 234.56 234.56 humana pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 234.56 234.56 humana ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 humana pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 humana ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 humana pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 humana ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 61.53 61.53 humana pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 61.53 61.53 humana ppo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 99.45 99.45 humana pos Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 99.45 99.45 humana ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 humana pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 humana ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 490.83 490.83 humana pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 490.83 490.83 humana ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 88.96 88.96 humana pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 88.96 88.96 humana ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 35.45 35.45 humana pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 35.45 35.45 humana ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 1760.46 1760.46 humana pos Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 1760.46 1760.46 humana ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 259.33 259.33 humana pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 259.33 259.33 humana ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 45.55 45.55 humana pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 45.55 45.55 humana ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 51.68 51.68 humana pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 51.68 51.68 humana ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 77.12 77.12 humana pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 77.12 77.12 humana ppo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 73.11 73.11 humana pos "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 73.11 73.11 humana ppo Drugs requiring detailed coding revCode 636 1760.46 1760.46 1760.46 1760.46 3320.41 3320.41 2767.01 2767.01 E 1760.46 1760.46 humana pos Drugs requiring detailed coding revCode 636 1760.46 1760.46 1760.46 1760.46 3320.41 3320.41 2767.01 2767.01 E 1760.46 1760.46 humana ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1760.46 1760.46 humana pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1760.46 1760.46 humana ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 81.09 81.09 humana pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 81.09 81.09 humana ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 humana pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 humana ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 261.58 261.58 humana pos Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 261.58 261.58 humana ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 166.07 166.07 humana pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 166.07 166.07 humana ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 37.92 37.92 humana pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 37.92 37.92 humana ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 59.86 59.86 humana pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 59.86 59.86 humana ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1760.46 1760.46 humana pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 1760.46 1760.46 humana ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 56.16 56.16 humana pos "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 56.16 56.16 humana ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 humana pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 humana ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1760.46 1760.46 humana pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 1760.46 1760.46 humana ppo "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 1444.99 1444.99 humana medicare advantage hmo "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 1444.99 1444.99 humana medicare advantage pos "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 1444.99 1444.99 humana medicare advantage ppo "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 1444.99 1444.99 humana medicare advantage hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 3.28 3.28 humana medicare advantage hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 3.28 3.28 humana medicare advantage pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 3.28 3.28 humana medicare advantage ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 3.28 3.28 humana medicare advantage hmo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.2 7.2 humana medicare advantage hmo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.2 7.2 humana medicare advantage pos Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.2 7.2 humana medicare advantage ppo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 7.2 7.2 humana medicare advantage hmo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 humana medicare advantage hmo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 humana medicare advantage pos Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 humana medicare advantage ppo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 11.53 11.53 humana medicare advantage hmo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 18.58 18.58 humana medicare advantage hmo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 18.58 18.58 humana medicare advantage pos "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 18.58 18.58 humana medicare advantage ppo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 18.58 18.58 humana medicare advantage hmo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 12.58 12.58 humana medicare advantage hmo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 12.58 12.58 humana medicare advantage pos Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 12.58 12.58 humana medicare advantage ppo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 12.58 12.58 humana medicare advantage hmo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 9.71 9.71 humana medicare advantage hmo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 9.71 9.71 humana medicare advantage pos Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 9.71 9.71 humana medicare advantage ppo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 9.71 9.71 humana medicare advantage hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 humana medicare advantage hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 humana medicare advantage pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 humana medicare advantage ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 humana medicare advantage hmo Hydroxyindolacetic acid (product of metabolism) level cpt 83497 14.39 14.39 11.47 11.47 228.96 228.96 190.8 190.8 O 12.9 12.9 humana medicare advantage hmo Hydroxyindolacetic acid (product of metabolism) level cpt 83497 14.39 14.39 11.47 11.47 228.96 228.96 190.8 190.8 O 12.9 12.9 humana medicare advantage pos Hydroxyindolacetic acid (product of metabolism) level cpt 83497 14.39 14.39 11.47 11.47 228.96 228.96 190.8 190.8 O 12.9 12.9 humana medicare advantage ppo Hydroxyindolacetic acid (product of metabolism) level cpt 83497 14.39 14.39 11.47 11.47 228.96 228.96 190.8 190.8 O 12.9 12.9 humana medicare advantage hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 humana medicare advantage hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 humana medicare advantage pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 humana medicare advantage ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 humana medicare advantage hmo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.53 11.53 humana medicare advantage hmo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.53 11.53 humana medicare advantage pos "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.53 11.53 humana medicare advantage ppo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 11.53 11.53 humana medicare advantage hmo Measurement of substance using immunoassay technique cpt 83520 33.85 33.85 15.36 15.36 39.43 39.43 32.86 32.86 O 17.27 17.27 humana medicare advantage hmo Measurement of substance using immunoassay technique cpt 83520 33.85 33.85 15.36 15.36 39.43 39.43 32.86 32.86 O 17.27 17.27 humana medicare advantage pos Measurement of substance using immunoassay technique cpt 83520 33.85 33.85 15.36 15.36 39.43 39.43 32.86 32.86 O 17.27 17.27 humana medicare advantage ppo Measurement of substance using immunoassay technique cpt 83520 33.85 33.85 15.36 15.36 39.43 39.43 32.86 32.86 O 17.27 17.27 humana medicare advantage hmo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 9.46 9.46 humana medicare advantage hmo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 9.46 9.46 humana medicare advantage pos Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 9.46 9.46 humana medicare advantage ppo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 9.46 9.46 humana medicare advantage hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 humana medicare advantage hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 humana medicare advantage pos Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 humana medicare advantage ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 humana medicare advantage hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 humana medicare advantage hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 humana medicare advantage pos Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 humana medicare advantage ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 humana medicare advantage hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 6.04 6.04 humana medicare advantage hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 6.04 6.04 humana medicare advantage pos Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 6.04 6.04 humana medicare advantage ppo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 6.04 6.04 humana medicare advantage hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 humana medicare advantage hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 humana medicare advantage pos Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 humana medicare advantage ppo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 5.18 5.18 humana medicare advantage hmo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 19.7 19.7 humana medicare advantage hmo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 19.7 19.7 humana medicare advantage pos Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 19.7 19.7 humana medicare advantage ppo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 19.7 19.7 humana medicare advantage hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 5.12 5.12 humana medicare advantage hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 5.12 5.12 humana medicare advantage pos Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 5.12 5.12 humana medicare advantage ppo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 5.12 5.12 humana medicare advantage hmo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 humana medicare advantage hmo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 humana medicare advantage pos Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 humana medicare advantage ppo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 6.89 6.89 humana medicare advantage hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 humana medicare advantage hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 humana medicare advantage pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 humana medicare advantage ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 humana medicare advantage hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 11.55 11.55 humana medicare advantage hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 11.55 11.55 humana medicare advantage pos "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 11.55 11.55 humana medicare advantage ppo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 11.55 11.55 humana medicare advantage hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 humana medicare advantage hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 humana medicare advantage pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 humana medicare advantage ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 humana medicare advantage hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 6.45 6.45 humana medicare advantage hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 6.45 6.45 humana medicare advantage pos "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 6.45 6.45 humana medicare advantage ppo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 6.45 6.45 humana medicare advantage hmo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 humana medicare advantage hmo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 humana medicare advantage pos "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 humana medicare advantage ppo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 27.2 27.2 humana medicare advantage hmo Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 21.21 21.21 humana medicare advantage hmo Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 21.21 21.21 humana medicare advantage pos Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 21.21 21.21 humana medicare advantage ppo Organic acid level cpt 83921 21.3 21.3 16.85 16.85 110.66 110.66 92.22 92.22 O 21.21 21.21 humana medicare advantage hmo Blood osmolality (concentration) measurement cpt 83930 6.61 6.61 5.88 5.88 128.47 128.47 107.06 107.06 O 6.61 6.61 humana medicare advantage hmo Blood osmolality (concentration) measurement cpt 83930 6.61 6.61 5.88 5.88 128.47 128.47 107.06 107.06 O 6.61 6.61 humana medicare advantage pos Blood osmolality (concentration) measurement cpt 83930 6.61 6.61 5.88 5.88 128.47 128.47 107.06 107.06 O 6.61 6.61 humana medicare advantage ppo Blood osmolality (concentration) measurement cpt 83930 6.61 6.61 5.88 5.88 128.47 128.47 107.06 107.06 O 6.61 6.61 humana medicare advantage hmo Urine osmolality (concentration) measurement cpt 83935 6.82 6.82 6.07 6.07 109.39 109.39 91.16 91.16 O 6.82 6.82 humana medicare advantage hmo Urine osmolality (concentration) measurement cpt 83935 6.82 6.82 6.07 6.07 109.39 109.39 91.16 91.16 O 6.82 6.82 humana medicare advantage pos Urine osmolality (concentration) measurement cpt 83935 6.82 6.82 6.07 6.07 109.39 109.39 91.16 91.16 O 6.82 6.82 humana medicare advantage ppo Urine osmolality (concentration) measurement cpt 83935 6.82 6.82 6.07 6.07 109.39 109.39 91.16 91.16 O 6.82 6.82 humana medicare advantage hmo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 41.28 41.28 humana medicare advantage hmo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 41.28 41.28 humana medicare advantage pos Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 41.28 41.28 humana medicare advantage ppo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 41.28 41.28 humana medicare advantage hmo Body fluid pH level cpt 83986 3.58 3.58 3.58 3.58 11.34 11.34 9.45 9.45 O 3.58 3.58 humana medicare advantage hmo Body fluid pH level cpt 83986 3.58 3.58 3.58 3.58 11.34 11.34 9.45 9.45 O 3.58 3.58 humana medicare advantage pos Body fluid pH level cpt 83986 3.58 3.58 3.58 3.58 11.34 11.34 9.45 9.45 O 3.58 3.58 humana medicare advantage ppo Body fluid pH level cpt 83986 3.58 3.58 3.58 3.58 11.34 11.34 9.45 9.45 O 3.58 3.58 humana medicare advantage hmo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 16.3 16.3 humana medicare advantage hmo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 16.3 16.3 humana medicare advantage pos "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 16.3 16.3 humana medicare advantage ppo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 16.3 16.3 humana medicare advantage hmo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 humana medicare advantage hmo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 humana medicare advantage pos Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 humana medicare advantage ppo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 4.74 4.74 humana medicare advantage hmo "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 16.38 16.38 humana medicare advantage hmo "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 16.38 16.38 humana medicare advantage pos "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 16.38 16.38 humana medicare advantage ppo "Cortisol (hormone) measurement, free" cpt 82530 35.81 35.81 14.86 14.86 198.43 198.43 165.36 165.36 O 16.38 16.38 humana medicare advantage hmo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 12.41 12.41 humana medicare advantage hmo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 12.41 12.41 humana medicare advantage pos Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 12.41 12.41 humana medicare advantage ppo Copper level cpt 82525 39.38 39.38 11.04 11.04 77.59 77.59 64.66 64.66 O 12.41 12.41 humana medicare advantage hmo Urine potassium level cpt 84133 4.73 4.73 4.21 4.21 44.06 44.06 36.72 36.72 O 4.73 4.73 humana medicare advantage hmo Urine potassium level cpt 84133 4.73 4.73 4.21 4.21 44.06 44.06 36.72 36.72 O 4.73 4.73 humana medicare advantage pos Urine potassium level cpt 84133 4.73 4.73 4.21 4.21 44.06 44.06 36.72 36.72 O 4.73 4.73 humana medicare advantage ppo Urine potassium level cpt 84133 4.73 4.73 4.21 4.21 44.06 44.06 36.72 36.72 O 4.73 4.73 humana medicare advantage hmo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.59 14.59 humana medicare advantage hmo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.59 14.59 humana medicare advantage pos Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.59 14.59 humana medicare advantage ppo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 14.59 14.59 humana medicare advantage hmo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 humana medicare advantage hmo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 humana medicare advantage pos "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 humana medicare advantage ppo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 3.67 3.67 humana medicare advantage hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 3.67 3.67 humana medicare advantage hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 3.67 3.67 humana medicare advantage pos "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 3.67 3.67 humana medicare advantage ppo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 3.67 3.67 humana medicare advantage hmo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.11 5.11 humana medicare advantage hmo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.11 5.11 humana medicare advantage pos "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.11 5.11 humana medicare advantage ppo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 5.11 5.11 humana medicare advantage hmo "Total protein level, body fluid" cpt 84157 4 4 3.56 3.56 97.94 97.94 81.62 81.62 O 4 4 humana medicare advantage hmo "Total protein level, body fluid" cpt 84157 4 4 3.56 3.56 97.94 97.94 81.62 81.62 O 4 4 humana medicare advantage pos "Total protein level, body fluid" cpt 84157 4 4 3.56 3.56 97.94 97.94 81.62 81.62 O 4 4 humana medicare advantage ppo "Total protein level, body fluid" cpt 84157 4 4 3.56 3.56 97.94 97.94 81.62 81.62 O 4 4 humana medicare advantage hmo "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 37.73 37.73 humana medicare advantage hmo "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 37.73 37.73 humana medicare advantage pos "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 37.73 37.73 humana medicare advantage ppo "Dihydroxyvitamin D, 1, 25 level" cpt 82652 54.56 54.56 34.25 34.25 239.14 239.14 199.28 199.28 O 37.73 37.73 humana medicare advantage hmo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 humana medicare advantage hmo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 humana medicare advantage pos "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 humana medicare advantage ppo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 10.74 10.74 humana medicare advantage hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 29.6 29.6 humana medicare advantage hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 29.6 29.6 humana medicare advantage pos Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 29.6 29.6 humana medicare advantage ppo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 29.6 29.6 humana medicare advantage hmo "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 humana medicare advantage hmo "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 humana medicare advantage pos "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 humana medicare advantage ppo "Protein measurement, body fluid" cpt 84166 17.9 17.9 17.83 17.83 66.14 66.14 55.12 55.12 O 17.83 17.83 humana medicare advantage hmo Blood sodium level cpt 84295 4.81 4.81 3.22 3.22 40.44 40.44 33.7 33.7 O 4.81 4.81 humana medicare advantage hmo Blood sodium level cpt 84295 4.81 4.81 3.22 3.22 40.44 40.44 33.7 33.7 O 4.81 4.81 humana medicare advantage pos Blood sodium level cpt 84295 4.81 4.81 3.22 3.22 40.44 40.44 33.7 33.7 O 4.81 4.81 humana medicare advantage ppo Blood sodium level cpt 84295 4.81 4.81 3.22 3.22 40.44 40.44 33.7 33.7 O 4.81 4.81 humana medicare advantage hmo Urine sodium level cpt 84300 5.06 5.06 4.5 4.5 42.46 42.46 35.38 35.38 O 5.06 5.06 humana medicare advantage hmo Urine sodium level cpt 84300 5.06 5.06 4.5 4.5 42.46 42.46 35.38 35.38 O 5.06 5.06 humana medicare advantage pos Urine sodium level cpt 84300 5.06 5.06 4.5 4.5 42.46 42.46 35.38 35.38 O 5.06 5.06 humana medicare advantage ppo Urine sodium level cpt 84300 5.06 5.06 4.5 4.5 42.46 42.46 35.38 35.38 O 5.06 5.06 humana medicare advantage hmo Chemical analysis using spectrophotometry (light) cpt 84311 8.13 8.13 7.2 7.2 24.3 24.3 20.25 20.25 O 8.1 8.1 humana medicare advantage hmo Chemical analysis using spectrophotometry (light) cpt 84311 8.13 8.13 7.2 7.2 24.3 24.3 20.25 20.25 O 8.1 8.1 humana medicare advantage pos Chemical analysis using spectrophotometry (light) cpt 84311 8.13 8.13 7.2 7.2 24.3 24.3 20.25 20.25 O 8.1 8.1 humana medicare advantage ppo Chemical analysis using spectrophotometry (light) cpt 84311 8.13 8.13 7.2 7.2 24.3 24.3 20.25 20.25 O 8.1 8.1 humana medicare advantage hmo "Carbohydrate analysis, single qualitative" cpt 84376 5.5 5.5 5.5 5.5 25.61 25.61 21.34 21.34 O 5.5 5.5 humana medicare advantage hmo "Carbohydrate analysis, single qualitative" cpt 84376 5.5 5.5 5.5 5.5 25.61 25.61 21.34 21.34 O 5.5 5.5 humana medicare advantage pos "Carbohydrate analysis, single qualitative" cpt 84376 5.5 5.5 5.5 5.5 25.61 25.61 21.34 21.34 O 5.5 5.5 humana medicare advantage ppo "Carbohydrate analysis, single qualitative" cpt 84376 5.5 5.5 5.5 5.5 25.61 25.61 21.34 21.34 O 5.5 5.5 humana medicare advantage hmo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 25.47 25.47 humana medicare advantage hmo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 25.47 25.47 humana medicare advantage pos "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 25.47 25.47 humana medicare advantage ppo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 25.47 25.47 humana medicare advantage hmo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 25.81 25.81 humana medicare advantage hmo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 25.81 25.81 humana medicare advantage pos "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 25.81 25.81 humana medicare advantage ppo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 25.81 25.81 humana medicare advantage hmo Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 21.23 21.23 humana medicare advantage hmo Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 21.23 21.23 humana medicare advantage pos Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 21.23 21.23 humana medicare advantage ppo Vitamin B-1 (thiamine) level cpt 84425 23.54 23.54 18.88 18.88 148.82 148.82 124.02 124.02 O 21.23 21.23 humana medicare advantage hmo Thyroglobulin (thyroid related hormone) level cpt 84432 16.13 16.13 14.29 14.29 100.49 100.49 83.74 83.74 O 16.06 16.06 humana medicare advantage hmo Thyroglobulin (thyroid related hormone) level cpt 84432 16.13 16.13 14.29 14.29 100.49 100.49 83.74 83.74 O 16.06 16.06 humana medicare advantage pos Thyroglobulin (thyroid related hormone) level cpt 84432 16.13 16.13 14.29 14.29 100.49 100.49 83.74 83.74 O 16.06 16.06 humana medicare advantage ppo Thyroglobulin (thyroid related hormone) level cpt 84432 16.13 16.13 14.29 14.29 100.49 100.49 83.74 83.74 O 16.06 16.06 humana medicare advantage hmo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 6.87 6.87 humana medicare advantage hmo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 6.87 6.87 humana medicare advantage pos "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 6.87 6.87 humana medicare advantage ppo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 6.87 6.87 humana medicare advantage hmo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 4.38 4.38 humana medicare advantage hmo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 4.38 4.38 humana medicare advantage pos Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 4.38 4.38 humana medicare advantage ppo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 4.38 4.38 humana medicare advantage hmo Stool analysis for blood to screen for colon tumors cpt 82270 4.29 4.29 4.29 4.29 39.43 39.43 32.86 32.86 E 4.29 4.29 humana medicare advantage hmo Stool analysis for blood to screen for colon tumors cpt 82270 4.29 4.29 4.29 4.29 39.43 39.43 32.86 32.86 E 4.29 4.29 humana medicare advantage pos Stool analysis for blood to screen for colon tumors cpt 82270 4.29 4.29 4.29 4.29 39.43 39.43 32.86 32.86 E 4.29 4.29 humana medicare advantage ppo Stool analysis for blood to screen for colon tumors cpt 82270 4.29 4.29 4.29 4.29 39.43 39.43 32.86 32.86 E 4.29 4.29 humana medicare advantage hmo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 10434.91 10434.91 humana medicare advantage hmo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 10434.91 10434.91 humana medicare advantage pos complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 10434.91 10434.91 humana medicare advantage ppo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 10434.91 10434.91 humana medicare advantage hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 humana medicare advantage hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 humana medicare advantage pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 humana medicare advantage ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 humana medicare advantage hmo Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 14.18 14.18 humana medicare advantage hmo Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 14.18 14.18 humana medicare advantage pos Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 14.18 14.18 humana medicare advantage ppo Vitamin E level cpt 84446 14.18 14.18 12.66 12.66 90.31 90.31 75.26 75.26 O 14.18 14.18 humana medicare advantage hmo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 5.02 5.02 humana medicare advantage hmo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 5.02 5.02 humana medicare advantage pos "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 5.02 5.02 humana medicare advantage ppo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 5.02 5.02 humana medicare advantage hmo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 5.3 5.3 humana medicare advantage hmo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 5.3 5.3 humana medicare advantage pos "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 5.3 5.3 humana medicare advantage ppo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 5.3 5.3 humana medicare advantage hmo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 humana medicare advantage hmo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 humana medicare advantage pos Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 humana medicare advantage ppo Beta-2 microglobulin (protein) level cpt 82232 28.98 28.98 14.39 14.39 109.39 109.39 91.16 91.16 O 16.18 16.18 humana medicare advantage hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 humana medicare advantage hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 humana medicare advantage pos "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 humana medicare advantage ppo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 humana medicare advantage hmo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 21.09 21.09 humana medicare advantage hmo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 21.09 21.09 humana medicare advantage pos Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 21.09 21.09 humana medicare advantage ppo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 21.09 21.09 humana medicare advantage hmo Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 14.6 14.6 humana medicare advantage hmo Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 14.6 14.6 humana medicare advantage pos Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 14.6 14.6 humana medicare advantage ppo Angiotensin l - converting enzyme (ACE) level cpt 82164 21.69 21.69 12.99 12.99 109.39 109.39 91.16 91.16 O 14.6 14.6 humana medicare advantage hmo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 16.94 16.94 humana medicare advantage hmo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 16.94 16.94 humana medicare advantage pos "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 16.94 16.94 humana medicare advantage ppo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 16.94 16.94 humana medicare advantage hmo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 90.8 90.8 humana medicare advantage hmo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 90.8 90.8 humana medicare advantage pos "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 90.8 90.8 humana medicare advantage ppo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 90.8 90.8 humana medicare advantage hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 humana medicare advantage hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 humana medicare advantage pos Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 humana medicare advantage ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.48 6.48 humana medicare advantage hmo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 humana medicare advantage hmo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 humana medicare advantage pos "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 humana medicare advantage ppo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 12.47 12.47 humana medicare advantage hmo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 3.95 3.95 humana medicare advantage hmo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 3.95 3.95 humana medicare advantage pos "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 3.95 3.95 humana medicare advantage ppo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 3.95 3.95 humana medicare advantage hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.52 4.52 humana medicare advantage hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.52 4.52 humana medicare advantage pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.52 4.52 humana medicare advantage ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.52 4.52 humana medicare advantage hmo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage hmo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage pos Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage ppo Ammonia level cpt 82140 68.52 68.52 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage hmo Uric acid level cpt 84560 5.08 5.08 5.08 5.08 142.14 142.14 118.45 118.45 O 5.08 5.08 humana medicare advantage hmo Uric acid level cpt 84560 5.08 5.08 5.08 5.08 142.14 142.14 118.45 118.45 O 5.08 5.08 humana medicare advantage pos Uric acid level cpt 84560 5.08 5.08 5.08 5.08 142.14 142.14 118.45 118.45 O 5.08 5.08 humana medicare advantage ppo Uric acid level cpt 84560 5.08 5.08 5.08 5.08 142.14 142.14 118.45 118.45 O 5.08 5.08 humana medicare advantage hmo Vasoactive intestinal peptide (intestinal hormone) level cpt 84586 35.33 35.33 35.33 35.33 106 106 88.33 88.33 O 35.33 35.33 humana medicare advantage hmo Vasoactive intestinal peptide (intestinal hormone) level cpt 84586 35.33 35.33 35.33 35.33 106 106 88.33 88.33 O 35.33 35.33 humana medicare advantage pos Vasoactive intestinal peptide (intestinal hormone) level cpt 84586 35.33 35.33 35.33 35.33 106 106 88.33 88.33 O 35.33 35.33 humana medicare advantage ppo Vasoactive intestinal peptide (intestinal hormone) level cpt 84586 35.33 35.33 35.33 35.33 106 106 88.33 88.33 O 35.33 35.33 humana medicare advantage hmo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 16.77 16.77 humana medicare advantage hmo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 16.77 16.77 humana medicare advantage pos "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 16.77 16.77 humana medicare advantage ppo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 16.77 16.77 humana medicare advantage hmo "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 13.44 13.44 humana medicare advantage hmo "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 13.44 13.44 humana medicare advantage pos "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 13.44 13.44 humana medicare advantage ppo "Alpha-1-antitrypsin (protein) blood test, total" cpt 82103 13.44 13.44 11.95 11.95 80.14 80.14 66.78 66.78 O 13.44 13.44 humana medicare advantage hmo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 20.81 20.81 humana medicare advantage hmo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 20.81 20.81 humana medicare advantage pos C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 20.81 20.81 humana medicare advantage ppo C-peptide (protein) level cpt 84681 49.41 49.41 18.51 18.51 100.49 100.49 83.74 83.74 O 20.81 20.81 humana medicare advantage hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 humana medicare advantage hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 humana medicare advantage pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 humana medicare advantage ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 humana medicare advantage hmo Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 37.89 37.89 humana medicare advantage hmo Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 37.89 37.89 humana medicare advantage pos Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 37.89 37.89 humana medicare advantage ppo Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 37.89 37.89 humana medicare advantage hmo "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 8.17 8.17 humana medicare advantage hmo "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 8.17 8.17 humana medicare advantage pos "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 8.17 8.17 humana medicare advantage ppo "Ketone bodies analysis, quantitative" cpt 82010 16.5 16.5 7.27 7.27 90.36 90.36 75.3 75.3 O 8.17 8.17 humana medicare advantage hmo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 3.99 3.99 humana medicare advantage hmo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 3.99 3.99 humana medicare advantage pos "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 3.99 3.99 humana medicare advantage ppo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 3.99 3.99 humana medicare advantage hmo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 4.48 4.48 humana medicare advantage hmo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 4.48 4.48 humana medicare advantage pos "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 4.48 4.48 humana medicare advantage ppo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 4.48 4.48 humana medicare advantage hmo Gene analysis (hemochromatosis) common variants cpt 81256 64.05 64.05 64.05 64.05 382.87 382.87 319.06 319.06 E 64.05 64.05 humana medicare advantage hmo Gene analysis (hemochromatosis) common variants cpt 81256 64.05 64.05 64.05 64.05 382.87 382.87 319.06 319.06 E 64.05 64.05 humana medicare advantage pos Gene analysis (hemochromatosis) common variants cpt 81256 64.05 64.05 64.05 64.05 382.87 382.87 319.06 319.06 E 64.05 64.05 humana medicare advantage ppo Gene analysis (hemochromatosis) common variants cpt 81256 64.05 64.05 64.05 64.05 382.87 382.87 319.06 319.06 E 64.05 64.05 humana medicare advantage hmo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 3.64 3.64 humana medicare advantage hmo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 3.64 3.64 humana medicare advantage pos Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 3.64 3.64 humana medicare advantage ppo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 3.64 3.64 humana medicare advantage hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 10.18 10.18 humana medicare advantage hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 10.18 10.18 humana medicare advantage pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 10.18 10.18 humana medicare advantage ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 10.18 10.18 humana medicare advantage hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 humana medicare advantage hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 humana medicare advantage pos "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 humana medicare advantage ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 humana medicare advantage hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 17.14 17.14 humana medicare advantage hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 17.14 17.14 humana medicare advantage pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 17.14 17.14 humana medicare advantage ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 17.14 17.14 humana medicare advantage hmo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 15.05 15.05 humana medicare advantage hmo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 15.05 15.05 humana medicare advantage pos Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 15.05 15.05 humana medicare advantage ppo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 15.05 15.05 humana medicare advantage hmo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 12.09 12.09 humana medicare advantage hmo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 12.09 12.09 humana medicare advantage pos Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 12.09 12.09 humana medicare advantage ppo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 12.09 12.09 humana medicare advantage hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 humana medicare advantage hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 humana medicare advantage pos Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 humana medicare advantage ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 humana medicare advantage hmo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 12.95 12.95 humana medicare advantage hmo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 12.95 12.95 humana medicare advantage pos "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 12.95 12.95 humana medicare advantage ppo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 12.95 12.95 humana medicare advantage hmo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 humana medicare advantage hmo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 humana medicare advantage pos Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 humana medicare advantage ppo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 humana medicare advantage hmo Theophylline level cpt 80198 14.14 14.14 14.14 14.14 106.85 106.85 89.04 89.04 O 14.14 14.14 humana medicare advantage hmo Theophylline level cpt 80198 14.14 14.14 14.14 14.14 106.85 106.85 89.04 89.04 O 14.14 14.14 humana medicare advantage pos Theophylline level cpt 80198 14.14 14.14 14.14 14.14 106.85 106.85 89.04 89.04 O 14.14 14.14 humana medicare advantage ppo Theophylline level cpt 80198 14.14 14.14 14.14 14.14 106.85 106.85 89.04 89.04 O 14.14 14.14 humana medicare advantage hmo "Measurement of complement (immune system proteins), antigen," cpt 86160 12.05 12.05 10.67 10.67 54.7 54.7 45.58 45.58 O 12 12 humana medicare advantage hmo "Measurement of complement (immune system proteins), antigen," cpt 86160 12.05 12.05 10.67 10.67 54.7 54.7 45.58 45.58 O 12 12 humana medicare advantage pos "Measurement of complement (immune system proteins), antigen," cpt 86160 12.05 12.05 10.67 10.67 54.7 54.7 45.58 45.58 O 12 12 humana medicare advantage ppo "Measurement of complement (immune system proteins), antigen," cpt 86160 12.05 12.05 10.67 10.67 54.7 54.7 45.58 45.58 O 12 12 humana medicare advantage hmo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 humana medicare advantage hmo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 humana medicare advantage pos "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 humana medicare advantage ppo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 humana medicare advantage hmo Tacrolimus level cpt 80197 13.73 13.73 13.46 13.46 727.58 727.58 606.32 606.32 O 13.73 13.73 humana medicare advantage hmo Tacrolimus level cpt 80197 13.73 13.73 13.46 13.46 727.58 727.58 606.32 606.32 O 13.73 13.73 humana medicare advantage pos Tacrolimus level cpt 80197 13.73 13.73 13.46 13.46 727.58 727.58 606.32 606.32 O 13.73 13.73 humana medicare advantage ppo Tacrolimus level cpt 80197 13.73 13.73 13.46 13.46 727.58 727.58 606.32 606.32 O 13.73 13.73 humana medicare advantage hmo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 12.95 12.95 humana medicare advantage hmo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 12.95 12.95 humana medicare advantage pos Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 12.95 12.95 humana medicare advantage ppo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 12.95 12.95 humana medicare advantage hmo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 13.25 13.25 humana medicare advantage hmo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 13.25 13.25 humana medicare advantage pos "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 13.25 13.25 humana medicare advantage ppo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 13.25 13.25 humana medicare advantage hmo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 17.93 17.93 humana medicare advantage hmo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 17.93 17.93 humana medicare advantage pos "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 17.93 17.93 humana medicare advantage ppo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 17.93 17.93 humana medicare advantage hmo Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 6.61 6.61 humana medicare advantage hmo Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 6.61 6.61 humana medicare advantage pos Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 6.61 6.61 humana medicare advantage ppo Lithium level cpt 80178 27.09 27.09 5.88 5.88 60.67 60.67 50.56 50.56 O 6.61 6.61 humana medicare advantage hmo Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 humana medicare advantage hmo Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 humana medicare advantage pos Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 humana medicare advantage ppo Levetiracetam level cpt 80177 13.25 13.25 11.79 11.79 77.59 77.59 64.66 64.66 O 13.25 13.25 humana medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 humana medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 humana medicare advantage pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 humana medicare advantage ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.81 20.81 humana medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" cpt 86304 43.28 43.28 18.51 18.51 109.39 109.39 91.16 91.16 O 20.81 20.81 humana medicare advantage hmo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 13.54 13.54 humana medicare advantage hmo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 13.54 13.54 humana medicare advantage pos "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 13.54 13.54 humana medicare advantage ppo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 13.54 13.54 humana medicare advantage hmo Analysis for detection of tumor marker cpt 86316 22.06 22.06 18.51 18.51 133.56 133.56 111.3 111.3 O 20.81 20.81 humana medicare advantage hmo Analysis for detection of tumor marker cpt 86316 22.06 22.06 18.51 18.51 133.56 133.56 111.3 111.3 O 20.81 20.81 humana medicare advantage pos Analysis for detection of tumor marker cpt 86316 22.06 22.06 18.51 18.51 133.56 133.56 111.3 111.3 O 20.81 20.81 humana medicare advantage ppo Analysis for detection of tumor marker cpt 86316 22.06 22.06 18.51 18.51 133.56 133.56 111.3 111.3 O 20.81 20.81 humana medicare advantage hmo "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 13.15 13.15 humana medicare advantage hmo "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 13.15 13.15 humana medicare advantage pos "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 13.15 13.15 humana medicare advantage ppo "Digoxin level, total" cpt 80162 15.53 15.53 13.01 13.01 109.26 109.26 91.05 91.05 O 13.15 13.15 humana medicare advantage hmo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 humana medicare advantage hmo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 humana medicare advantage pos Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 humana medicare advantage ppo Immunologic analysis technique on serum (immunofixation) cpt 86334 22.43 22.43 19.87 19.87 142.46 142.46 118.72 118.72 O 22.34 22.34 humana medicare advantage hmo "Carbamazepine level, total" cpt 80156 14.57 14.57 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage hmo "Carbamazepine level, total" cpt 80156 14.57 14.57 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage pos "Carbamazepine level, total" cpt 80156 14.57 14.57 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage ppo "Carbamazepine level, total" cpt 80156 14.57 14.57 12.96 12.96 117.02 117.02 97.52 97.52 O 14.57 14.57 humana medicare advantage hmo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 47.63 47.63 humana medicare advantage hmo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 47.63 47.63 humana medicare advantage pos Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 47.63 47.63 humana medicare advantage ppo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 47.63 47.63 humana medicare advantage hmo "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 humana medicare advantage hmo "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 humana medicare advantage pos "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 humana medicare advantage ppo "Immunologic analysis technique on body fluid, other fluids with concentration" cpt 86335 29.47 29.47 29.35 29.35 228.96 228.96 190.8 190.8 O 29.35 29.35 humana medicare advantage hmo Insulin antibody measurement cpt 86337 21.41 21.41 19.04 19.04 109.39 109.39 91.16 91.16 O 21.41 21.41 humana medicare advantage hmo Insulin antibody measurement cpt 86337 21.41 21.41 19.04 19.04 109.39 109.39 91.16 91.16 O 21.41 21.41 humana medicare advantage pos Insulin antibody measurement cpt 86337 21.41 21.41 19.04 19.04 109.39 109.39 91.16 91.16 O 21.41 21.41 humana medicare advantage ppo Insulin antibody measurement cpt 86337 21.41 21.41 19.04 19.04 109.39 109.39 91.16 91.16 O 21.41 21.41 humana medicare advantage hmo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.55 14.55 humana medicare advantage hmo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.55 14.55 humana medicare advantage pos Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.55 14.55 humana medicare advantage ppo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 14.55 14.55 humana medicare advantage hmo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 11.54 11.54 humana medicare advantage hmo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 11.54 11.54 humana medicare advantage pos Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 11.54 11.54 humana medicare advantage ppo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 11.54 11.54 humana medicare advantage hmo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 7.01 7.01 humana medicare advantage hmo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 7.01 7.01 humana medicare advantage pos "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 7.01 7.01 humana medicare advantage ppo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 7.01 7.01 humana medicare advantage hmo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.14 6.14 humana medicare advantage hmo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.14 6.14 humana medicare advantage pos Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.14 6.14 humana medicare advantage ppo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 6.14 6.14 humana medicare advantage hmo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 61.98 61.98 humana medicare advantage hmo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 61.98 61.98 humana medicare advantage pos "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 61.98 61.98 humana medicare advantage ppo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 61.98 61.98 humana medicare advantage hmo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 4.27 4.27 humana medicare advantage hmo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 4.27 4.27 humana medicare advantage pos Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 4.27 4.27 humana medicare advantage ppo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 4.27 4.27 humana medicare advantage hmo "Radioactive material therapy into vein, not radiolabeled" cpt 79101 210.31 210.31 210.31 210.31 627.1 627.1 522.58 522.58 O 210.31 210.31 humana medicare advantage hmo "Radioactive material therapy into vein, not radiolabeled" cpt 79101 210.31 210.31 210.31 210.31 627.1 627.1 522.58 522.58 O 210.31 210.31 humana medicare advantage pos "Radioactive material therapy into vein, not radiolabeled" cpt 79101 210.31 210.31 210.31 210.31 627.1 627.1 522.58 522.58 O 210.31 210.31 humana medicare advantage ppo "Radioactive material therapy into vein, not radiolabeled" cpt 79101 210.31 210.31 210.31 210.31 627.1 627.1 522.58 522.58 O 210.31 210.31 humana medicare advantage hmo Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 17.03 17.03 humana medicare advantage hmo Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 17.03 17.03 humana medicare advantage pos Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 17.03 17.03 humana medicare advantage ppo Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) cpt 86618 44.5 44.5 15.15 15.15 305.28 305.28 254.4 254.4 O 17.03 17.03 humana medicare advantage hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 humana medicare advantage hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 humana medicare advantage pos Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 humana medicare advantage ppo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 humana medicare advantage hmo "Nuclear medicine study of kidney with assessment of blood flow and function, with or without drugs, multiple studies" cpt 78709 418.12 418.12 260.45 260.45 1436.09 1436.09 1196.74 1196.74 O 418.12 418.12 humana medicare advantage hmo "Nuclear medicine study of kidney with assessment of blood flow and function, with or without drugs, multiple studies" cpt 78709 418.12 418.12 260.45 260.45 1436.09 1436.09 1196.74 1196.74 O 418.12 418.12 humana medicare advantage pos "Nuclear medicine study of kidney with assessment of blood flow and function, with or without drugs, multiple studies" cpt 78709 418.12 418.12 260.45 260.45 1436.09 1436.09 1196.74 1196.74 O 418.12 418.12 humana medicare advantage ppo "Nuclear medicine study of kidney with assessment of blood flow and function, with or without drugs, multiple studies" cpt 78709 418.12 418.12 260.45 260.45 1436.09 1436.09 1196.74 1196.74 O 418.12 418.12 humana medicare advantage hmo "Nuclear medicine study of heart wall motion at rest or stress with evaluation of blood ejection from heart, single study, gated equilibrium" cpt 78472 326.12 326.12 320.9 320.9 2477.86 2477.86 2064.88 2064.88 O 326.12 326.12 humana medicare advantage hmo "Nuclear medicine study of heart wall motion at rest or stress with evaluation of blood ejection from heart, single study, gated equilibrium" cpt 78472 326.12 326.12 320.9 320.9 2477.86 2477.86 2064.88 2064.88 O 326.12 326.12 humana medicare advantage pos "Nuclear medicine study of heart wall motion at rest or stress with evaluation of blood ejection from heart, single study, gated equilibrium" cpt 78472 326.12 326.12 320.9 320.9 2477.86 2477.86 2064.88 2064.88 O 326.12 326.12 humana medicare advantage ppo "Nuclear medicine study of heart wall motion at rest or stress with evaluation of blood ejection from heart, single study, gated equilibrium" cpt 78472 326.12 326.12 320.9 320.9 2477.86 2477.86 2064.88 2064.88 O 326.12 326.12 humana medicare advantage hmo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 13.19 13.19 humana medicare advantage hmo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 13.19 13.19 humana medicare advantage pos "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 13.19 13.19 humana medicare advantage ppo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 13.19 13.19 humana medicare advantage hmo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 19.35 19.35 humana medicare advantage hmo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 19.35 19.35 humana medicare advantage pos "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 19.35 19.35 humana medicare advantage ppo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 19.35 19.35 humana medicare advantage hmo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 12.05 12.05 humana medicare advantage hmo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 12.05 12.05 humana medicare advantage pos Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 12.05 12.05 humana medicare advantage ppo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 12.05 12.05 humana medicare advantage hmo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 11.65 11.65 humana medicare advantage hmo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 11.65 11.65 humana medicare advantage pos Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 11.65 11.65 humana medicare advantage ppo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 11.65 11.65 humana medicare advantage hmo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 10.74 10.74 humana medicare advantage hmo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 10.74 10.74 humana medicare advantage pos Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 10.74 10.74 humana medicare advantage ppo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 10.74 10.74 humana medicare advantage hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1127.01 1127.01 humana medicare advantage hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1127.01 1127.01 humana medicare advantage pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1127.01 1127.01 humana medicare advantage ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1127.01 1127.01 humana medicare advantage hmo Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 11.26 11.26 humana medicare advantage hmo Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 11.26 11.26 humana medicare advantage pos Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 11.26 11.26 humana medicare advantage ppo Measurement of Hepatitis A antibody (IgM) cpt 86709 58.16 58.16 10.02 10.02 114.6 114.6 95.5 95.5 O 11.26 11.26 humana medicare advantage hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 1127.01 1127.01 humana medicare advantage hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 1127.01 1127.01 humana medicare advantage pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 1127.01 1127.01 humana medicare advantage ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 1127.01 1127.01 humana medicare advantage hmo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 326.12 326.12 humana medicare advantage hmo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 326.12 326.12 humana medicare advantage pos "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 326.12 326.12 humana medicare advantage ppo "Bone and/or joint imaging, whole body" cpt 78306 522.98 522.98 227.53 227.53 1878 1878 1565 1565 O 326.12 326.12 humana medicare advantage hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 415.66 415.66 humana medicare advantage hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 415.66 415.66 humana medicare advantage pos Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 415.66 415.66 humana medicare advantage ppo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 415.66 415.66 humana medicare advantage hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 12.88 12.88 humana medicare advantage hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 12.88 12.88 humana medicare advantage pos Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 12.88 12.88 humana medicare advantage ppo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 12.88 12.88 humana medicare advantage hmo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.91 15.91 humana medicare advantage hmo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.91 15.91 humana medicare advantage pos Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.91 15.91 humana medicare advantage ppo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 15.91 15.91 humana medicare advantage hmo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 14.27 14.27 humana medicare advantage hmo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 14.27 14.27 humana medicare advantage pos Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 14.27 14.27 humana medicare advantage ppo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 14.27 14.27 humana medicare advantage hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 78 78 humana medicare advantage hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 78 78 humana medicare advantage pos Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 78 78 humana medicare advantage ppo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 78 78 humana medicare advantage hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 209.39 209.39 humana medicare advantage hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 209.39 209.39 humana medicare advantage pos "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 209.39 209.39 humana medicare advantage ppo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 209.39 209.39 humana medicare advantage hmo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 29.61 29.61 humana medicare advantage hmo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 29.61 29.61 humana medicare advantage pos "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 29.61 29.61 humana medicare advantage ppo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 29.61 29.61 humana medicare advantage hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 96.59 96.59 humana medicare advantage hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 96.59 96.59 humana medicare advantage pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 96.59 96.59 humana medicare advantage ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 96.59 96.59 humana medicare advantage hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 477.34 477.34 humana medicare advantage hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 477.34 477.34 humana medicare advantage pos "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 477.34 477.34 humana medicare advantage ppo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 477.34 477.34 humana medicare advantage hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 70.1 70.1 humana medicare advantage hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 70.1 70.1 humana medicare advantage pos Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 70.1 70.1 humana medicare advantage ppo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 70.1 70.1 humana medicare advantage hmo "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 467.79 467.79 humana medicare advantage hmo "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 467.79 467.79 humana medicare advantage pos "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 467.79 467.79 humana medicare advantage ppo "Intensity modulated radiation therapy delivery, simple" cpt 77385 717.88 717.88 467.79 467.79 1925.81 1925.81 1604.84 1604.84 O 467.79 467.79 humana medicare advantage hmo Stereotactic body radiation therapy 1 or more lesions using imaging guidance cpt 77373 2884.88 2884.88 1536.3 1536.3 4710 4710 3925 3925 O 1536.3 1536.3 humana medicare advantage hmo Stereotactic body radiation therapy 1 or more lesions using imaging guidance cpt 77373 2884.88 2884.88 1536.3 1536.3 4710 4710 3925 3925 O 1536.3 1536.3 humana medicare advantage pos Stereotactic body radiation therapy 1 or more lesions using imaging guidance cpt 77373 2884.88 2884.88 1536.3 1536.3 4710 4710 3925 3925 O 1536.3 1536.3 humana medicare advantage ppo Stereotactic body radiation therapy 1 or more lesions using imaging guidance cpt 77373 2884.88 2884.88 1536.3 1536.3 4710 4710 3925 3925 O 1536.3 1536.3 humana medicare advantage hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 62.74 62.74 humana medicare advantage hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 62.74 62.74 humana medicare advantage pos "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 62.74 62.74 humana medicare advantage ppo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 62.74 62.74 humana medicare advantage hmo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 296.91 296.91 humana medicare advantage hmo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 296.91 296.91 humana medicare advantage pos Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 296.91 296.91 humana medicare advantage ppo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 296.91 296.91 humana medicare advantage hmo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 9.44 9.44 humana medicare advantage hmo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 9.44 9.44 humana medicare advantage pos Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 9.44 9.44 humana medicare advantage ppo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 9.44 9.44 humana medicare advantage hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 112.14 112.14 humana medicare advantage hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 112.14 112.14 humana medicare advantage pos Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 112.14 112.14 humana medicare advantage ppo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 112.14 112.14 humana medicare advantage hmo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.44 9.44 humana medicare advantage hmo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.44 9.44 humana medicare advantage pos "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.44 9.44 humana medicare advantage ppo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 9.44 9.44 humana medicare advantage hmo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 8.62 8.62 humana medicare advantage hmo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 8.62 8.62 humana medicare advantage pos "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 8.62 8.62 humana medicare advantage ppo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 8.62 8.62 humana medicare advantage hmo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 9.47 9.47 humana medicare advantage hmo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 9.47 9.47 humana medicare advantage pos "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 9.47 9.47 humana medicare advantage ppo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 9.47 9.47 humana medicare advantage hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 humana medicare advantage hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 humana medicare advantage pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 humana medicare advantage ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 humana medicare advantage hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 humana medicare advantage hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 humana medicare advantage pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 humana medicare advantage ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 296.91 296.91 humana medicare advantage hmo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 6.63 6.63 humana medicare advantage hmo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 6.63 6.63 humana medicare advantage pos Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 6.63 6.63 humana medicare advantage ppo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 6.63 6.63 humana medicare advantage hmo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 humana medicare advantage hmo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 humana medicare advantage pos Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 humana medicare advantage ppo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 humana medicare advantage hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 humana medicare advantage hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 humana medicare advantage pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 humana medicare advantage ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 humana medicare advantage hmo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.41 8.41 humana medicare advantage hmo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.41 8.41 humana medicare advantage pos Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.41 8.41 humana medicare advantage ppo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 8.41 8.41 humana medicare advantage hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 humana medicare advantage hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 humana medicare advantage pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 humana medicare advantage ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 humana medicare advantage hmo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1103.22 1103.22 humana medicare advantage hmo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1103.22 1103.22 humana medicare advantage pos Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1103.22 1103.22 humana medicare advantage ppo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 1103.22 1103.22 humana medicare advantage hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 109.9 109.9 humana medicare advantage hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 109.9 109.9 humana medicare advantage pos Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 109.9 109.9 humana medicare advantage ppo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 109.9 109.9 humana medicare advantage hmo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 8.9 8.9 humana medicare advantage hmo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 8.9 8.9 humana medicare advantage pos Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 8.9 8.9 humana medicare advantage ppo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 8.9 8.9 humana medicare advantage hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 4.75 4.75 humana medicare advantage hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 4.75 4.75 humana medicare advantage pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 4.75 4.75 humana medicare advantage ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 4.75 4.75 humana medicare advantage hmo "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" cpt 87185 4.75 4.75 4.23 4.23 20.95 20.95 17.46 17.46 O 4.75 4.75 humana medicare advantage hmo "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" cpt 87185 4.75 4.75 4.23 4.23 20.95 20.95 17.46 17.46 O 4.75 4.75 humana medicare advantage pos "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" cpt 87185 4.75 4.75 4.23 4.23 20.95 20.95 17.46 17.46 O 4.75 4.75 humana medicare advantage ppo "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" cpt 87185 4.75 4.75 4.23 4.23 20.95 20.95 17.46 17.46 O 4.75 4.75 humana medicare advantage hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 humana medicare advantage hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 humana medicare advantage pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 humana medicare advantage ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 humana medicare advantage hmo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.27 4.27 humana medicare advantage hmo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.27 4.27 humana medicare advantage pos Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.27 4.27 humana medicare advantage ppo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 4.27 4.27 humana medicare advantage hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1092.69 1092.69 humana medicare advantage hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1092.69 1092.69 humana medicare advantage pos "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1092.69 1092.69 humana medicare advantage ppo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1092.69 1092.69 humana medicare advantage hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage pos Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage ppo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 humana medicare advantage hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 humana medicare advantage pos "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 humana medicare advantage ppo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 296.91 296.91 humana medicare advantage hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 14.38 14.38 humana medicare advantage hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 14.38 14.38 humana medicare advantage pos "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 14.38 14.38 humana medicare advantage ppo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 14.38 14.38 humana medicare advantage hmo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.33 10.33 humana medicare advantage hmo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.33 10.33 humana medicare advantage pos Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.33 10.33 humana medicare advantage ppo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 10.33 10.33 humana medicare advantage hmo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 112.14 112.14 humana medicare advantage hmo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 112.14 112.14 humana medicare advantage pos "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 112.14 112.14 humana medicare advantage ppo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 112.14 112.14 humana medicare advantage hmo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 24.08 24.08 humana medicare advantage hmo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 24.08 24.08 humana medicare advantage pos Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 24.08 24.08 humana medicare advantage ppo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 24.08 24.08 humana medicare advantage hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 99.29 99.29 humana medicare advantage hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 99.29 99.29 humana medicare advantage pos "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 99.29 99.29 humana medicare advantage ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 99.29 99.29 humana medicare advantage hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage pos Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage ppo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 11.98 11.98 humana medicare advantage hmo X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 99.29 99.29 humana medicare advantage hmo X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 99.29 99.29 humana medicare advantage pos X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 99.29 99.29 humana medicare advantage ppo X-ray survey of forearm or wrist bone density cpt 77075 99.29 99.29 61.44 61.44 747.94 747.94 623.28 623.28 O 99.29 99.29 humana medicare advantage hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 humana medicare advantage hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 humana medicare advantage pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 humana medicare advantage ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 humana medicare advantage hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 humana medicare advantage hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 humana medicare advantage pos "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 humana medicare advantage ppo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 37.27 37.27 humana medicare advantage hmo "Detection test by nucleic acid for cytomegalovirus, quantification" cpt 87497 42.84 42.84 38.11 38.11 250.58 250.58 208.82 208.82 O 42.84 42.84 humana medicare advantage hmo "Detection test by nucleic acid for cytomegalovirus, quantification" cpt 87497 42.84 42.84 38.11 38.11 250.58 250.58 208.82 208.82 O 42.84 42.84 humana medicare advantage pos "Detection test by nucleic acid for cytomegalovirus, quantification" cpt 87497 42.84 42.84 38.11 38.11 250.58 250.58 208.82 208.82 O 42.84 42.84 humana medicare advantage ppo "Detection test by nucleic acid for cytomegalovirus, quantification" cpt 87497 42.84 42.84 38.11 38.11 250.58 250.58 208.82 208.82 O 42.84 42.84 humana medicare advantage hmo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 99.29 99.29 humana medicare advantage hmo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 99.29 99.29 humana medicare advantage pos Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 99.29 99.29 humana medicare advantage ppo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 99.29 99.29 humana medicare advantage hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 humana medicare advantage hmo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 42.84 42.84 humana medicare advantage hmo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 42.84 42.84 humana medicare advantage pos "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 42.84 42.84 humana medicare advantage ppo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 42.84 42.84 humana medicare advantage hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 35.09 35.09 humana medicare advantage pos "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 35.09 35.09 humana medicare advantage ppo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 35.09 35.09 humana medicare advantage pos "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 35.09 35.09 humana medicare advantage ppo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 humana medicare advantage hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 humana medicare advantage pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 humana medicare advantage ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 humana medicare advantage hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 35.09 35.09 humana medicare advantage hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 35.09 35.09 humana medicare advantage pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 35.09 35.09 humana medicare advantage ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 35.09 35.09 humana medicare advantage hmo Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 257.45 257.45 humana medicare advantage hmo Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 257.45 257.45 humana medicare advantage pos Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 257.45 257.45 humana medicare advantage ppo Analysis test by nucleic acid for Hepatitis C virus cpt 87902 257.45 257.45 73.57 73.57 889.13 889.13 740.94 740.94 O 257.45 257.45 humana medicare advantage hmo "Screening examination of specimen cells, extended study" cpt 88162 50.58 50.58 43.82 43.82 580.98 580.98 484.15 484.15 O 43.82 43.82 humana medicare advantage hmo "Screening examination of specimen cells, extended study" cpt 88162 50.58 50.58 43.82 43.82 580.98 580.98 484.15 484.15 O 43.82 43.82 humana medicare advantage pos "Screening examination of specimen cells, extended study" cpt 88162 50.58 50.58 43.82 43.82 580.98 580.98 484.15 484.15 O 43.82 43.82 humana medicare advantage ppo "Screening examination of specimen cells, extended study" cpt 88162 50.58 50.58 43.82 43.82 580.98 580.98 484.15 484.15 O 43.82 43.82 humana medicare advantage hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 26.61 26.61 humana medicare advantage hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 26.61 26.61 humana medicare advantage pos "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 26.61 26.61 humana medicare advantage ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 26.61 26.61 humana medicare advantage hmo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 99.29 99.29 humana medicare advantage hmo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 99.29 99.29 humana medicare advantage pos "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 99.29 99.29 humana medicare advantage ppo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 99.29 99.29 humana medicare advantage hmo "Flow cytometry technique for DNA or cell analysis, first marker" cpt 88184 121.47 121.47 121.47 121.47 180 180 150 150 O 121.47 121.47 humana medicare advantage hmo "Flow cytometry technique for DNA or cell analysis, first marker" cpt 88184 121.47 121.47 121.47 121.47 180 180 150 150 O 121.47 121.47 humana medicare advantage pos "Flow cytometry technique for DNA or cell analysis, first marker" cpt 88184 121.47 121.47 121.47 121.47 180 180 150 150 O 121.47 121.47 humana medicare advantage ppo "Flow cytometry technique for DNA or cell analysis, first marker" cpt 88184 121.47 121.47 121.47 121.47 180 180 150 150 O 121.47 121.47 humana medicare advantage hmo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 99.29 99.29 humana medicare advantage hmo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 99.29 99.29 humana medicare advantage pos Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 99.29 99.29 humana medicare advantage ppo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 99.29 99.29 humana medicare advantage hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 43.82 43.82 humana medicare advantage hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 43.82 43.82 humana medicare advantage pos "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 43.82 43.82 humana medicare advantage ppo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 43.82 43.82 humana medicare advantage hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 99.29 99.29 humana medicare advantage hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 99.29 99.29 humana medicare advantage pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 99.29 99.29 humana medicare advantage ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 99.29 99.29 humana medicare advantage hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 humana medicare advantage hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 humana medicare advantage pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 humana medicare advantage ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 99.29 99.29 humana medicare advantage hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 70.7 70.7 humana medicare advantage hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 70.7 70.7 humana medicare advantage pos "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 70.7 70.7 humana medicare advantage ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 70.7 70.7 humana medicare advantage hmo "Special stained specimen slides to examine tissue, each multiplex procedure" cpt 88344 251.07 251.07 251.07 251.07 452.83 452.83 377.36 377.36 O 251.07 251.07 humana medicare advantage hmo "Special stained specimen slides to examine tissue, each multiplex procedure" cpt 88344 251.07 251.07 251.07 251.07 452.83 452.83 377.36 377.36 O 251.07 251.07 humana medicare advantage pos "Special stained specimen slides to examine tissue, each multiplex procedure" cpt 88344 251.07 251.07 251.07 251.07 452.83 452.83 377.36 377.36 O 251.07 251.07 humana medicare advantage ppo "Special stained specimen slides to examine tissue, each multiplex procedure" cpt 88344 251.07 251.07 251.07 251.07 452.83 452.83 377.36 377.36 O 251.07 251.07 humana medicare advantage hmo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 31.15 31.15 humana medicare advantage hmo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 31.15 31.15 humana medicare advantage pos "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 31.15 31.15 humana medicare advantage ppo "Microscopic genetic analysis of tumor, manual" cpt 88360 175.74 175.74 31.15 31.15 375.3 375.3 312.75 312.75 O 31.15 31.15 humana medicare advantage hmo "Microscopic genetic analysis of tissue, manual, initial procedure" cpt 88368 295 295 295 295 360 360 300 300 O 295 295 humana medicare advantage hmo "Microscopic genetic analysis of tissue, manual, initial procedure" cpt 88368 295 295 295 295 360 360 300 300 O 295 295 humana medicare advantage pos "Microscopic genetic analysis of tissue, manual, initial procedure" cpt 88368 295 295 295 295 360 360 300 300 O 295 295 humana medicare advantage ppo "Microscopic genetic analysis of tissue, manual, initial procedure" cpt 88368 295 295 295 295 360 360 300 300 O 295 295 humana medicare advantage hmo Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 5.6 5.6 humana medicare advantage hmo Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 5.6 5.6 humana medicare advantage pos Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 5.6 5.6 humana medicare advantage ppo Body fluid cell count with cell identification cpt 89051 19.36 19.36 4.98 4.98 45.91 45.91 38.26 38.26 O 5.6 5.6 humana medicare advantage hmo Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 7.33 7.33 humana medicare advantage hmo Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 7.33 7.33 humana medicare advantage pos Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 7.33 7.33 humana medicare advantage ppo Crystal identification from tissue or body fluid cpt 89060 18.24 18.24 6.52 6.52 43.25 43.25 36.04 36.04 O 7.33 7.33 humana medicare advantage hmo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 439.28 439.28 humana medicare advantage hmo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 439.28 439.28 humana medicare advantage pos Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 439.28 439.28 humana medicare advantage ppo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 439.28 439.28 humana medicare advantage hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 humana medicare advantage hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 humana medicare advantage pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 humana medicare advantage ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 humana medicare advantage hmo "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 8959.3 8959.3 humana medicare advantage hmo "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 8959.3 8959.3 humana medicare advantage pos "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 8959.3 8959.3 humana medicare advantage ppo "Vaccine for influenza for injection into muscle, inactivated" cpt 90653 8959.3 8959.3 1971.24 1971.24 14798.04 14798.04 12331.7 12331.7 E 8959.3 8959.3 humana medicare advantage hmo "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 50.63 50.63 humana medicare advantage hmo "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 50.63 50.63 humana medicare advantage pos "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 50.63 50.63 humana medicare advantage ppo "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 50.63 50.63 humana medicare advantage hmo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 2132.69 2132.69 2132.69 2132.69 16906.38 16906.38 14088.65 14088.65 E 2132.69 2132.69 humana medicare advantage hmo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 2132.69 2132.69 2132.69 2132.69 16906.38 16906.38 14088.65 14088.65 E 2132.69 2132.69 humana medicare advantage pos "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 2132.69 2132.69 2132.69 2132.69 16906.38 16906.38 14088.65 14088.65 E 2132.69 2132.69 humana medicare advantage ppo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 2132.69 2132.69 2132.69 2132.69 16906.38 16906.38 14088.65 14088.65 E 2132.69 2132.69 humana medicare advantage hmo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 601.12 601.12 humana medicare advantage hmo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 601.12 601.12 humana medicare advantage pos "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 601.12 601.12 humana medicare advantage ppo "Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, for injection into muscle, 0.5 ml dosage" cpt 90694 14191.44 14191.44 356.43 356.43 2486.09 2486.09 2071.74 2071.74 O 601.12 601.12 humana medicare advantage hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 517.94 517.94 humana medicare advantage hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 517.94 517.94 humana medicare advantage pos "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 517.94 517.94 humana medicare advantage ppo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 517.94 517.94 humana medicare advantage hmo Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 2455.02 2455.02 humana medicare advantage hmo Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 2455.02 2455.02 humana medicare advantage pos Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 2455.02 2455.02 humana medicare advantage ppo Radiological supervision and interpretation of imaging of arteries of both arms or legs cpt 75716 2455.02 2455.02 66.75 66.75 7289.83 7289.83 6074.86 6074.86 O 2455.02 2455.02 humana medicare advantage hmo CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 405.38 405.38 humana medicare advantage hmo CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 405.38 405.38 humana medicare advantage pos CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 405.38 405.38 humana medicare advantage ppo CT scan of abdominal aorta and both leg arteries with contrast cpt 75635 557.59 557.59 155.02 155.02 1985.59 1985.59 1654.66 1654.66 O 405.38 405.38 humana medicare advantage hmo Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2455.02 2455.02 humana medicare advantage hmo Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2455.02 2455.02 humana medicare advantage pos Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2455.02 2455.02 humana medicare advantage ppo Radiological supervision and interpretation X-ray of abdominal aorta cpt 75625 2526.65 2526.65 57.78 57.78 10861.61 10861.61 9051.34 9051.34 O 2455.02 2455.02 humana medicare advantage hmo "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 601.12 601.12 humana medicare advantage hmo "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 601.12 601.12 humana medicare advantage pos "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 601.12 601.12 humana medicare advantage ppo "Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older" cpt 90732 21516.54 21516.54 70.16 70.16 420 420 350 350 O 601.12 601.12 humana medicare advantage hmo "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 2193.6 2193.6 2042.78 2042.78 18736.39 18736.39 15613.66 15613.66 E 2193.6 2193.6 humana medicare advantage hmo "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 2193.6 2193.6 2042.78 2042.78 18736.39 18736.39 15613.66 15613.66 E 2193.6 2193.6 humana medicare advantage pos "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 2193.6 2193.6 2042.78 2042.78 18736.39 18736.39 15613.66 15613.66 E 2193.6 2193.6 humana medicare advantage ppo "Treatment of speech, language, voice, communication, and/or hearing processing disorder" cpt 92507 2193.6 2193.6 2042.78 2042.78 18736.39 18736.39 15613.66 15613.66 E 2193.6 2193.6 humana medicare advantage hmo Evaluation of speech sound production with evaluation of language comprehension and expression cpt 92523 2123.04 2123.04 1479.91 1479.91 16598.95 16598.95 13832.46 13832.46 E 2123.04 2123.04 humana medicare advantage hmo Evaluation of speech sound production with evaluation of language comprehension and expression cpt 92523 2123.04 2123.04 1479.91 1479.91 16598.95 16598.95 13832.46 13832.46 E 2123.04 2123.04 humana medicare advantage pos Evaluation of speech sound production with evaluation of language comprehension and expression cpt 92523 2123.04 2123.04 1479.91 1479.91 16598.95 16598.95 13832.46 13832.46 E 2123.04 2123.04 humana medicare advantage ppo Evaluation of speech sound production with evaluation of language comprehension and expression cpt 92523 2123.04 2123.04 1479.91 1479.91 16598.95 16598.95 13832.46 13832.46 E 2123.04 2123.04 humana medicare advantage hmo Treatment of swallowing and/or oral feeding function cpt 92526 2091.88 2091.88 2082.43 2082.43 12510.68 12510.68 10425.57 10425.57 E 2091.88 2091.88 humana medicare advantage hmo Treatment of swallowing and/or oral feeding function cpt 92526 2091.88 2091.88 2082.43 2082.43 12510.68 12510.68 10425.57 10425.57 E 2091.88 2091.88 humana medicare advantage pos Treatment of swallowing and/or oral feeding function cpt 92526 2091.88 2091.88 2082.43 2082.43 12510.68 12510.68 10425.57 10425.57 E 2091.88 2091.88 humana medicare advantage ppo Treatment of swallowing and/or oral feeding function cpt 92526 2091.88 2091.88 2082.43 2082.43 12510.68 12510.68 10425.57 10425.57 E 2091.88 2091.88 humana medicare advantage hmo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2052.6 2052.6 humana medicare advantage hmo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2052.6 2052.6 humana medicare advantage pos Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2052.6 2052.6 humana medicare advantage ppo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2052.6 2052.6 humana medicare advantage hmo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 2121.81 2121.81 1025.79 1025.79 17671.8 17671.8 14726.5 14726.5 E 2121.81 2121.81 humana medicare advantage hmo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 2121.81 2121.81 1025.79 1025.79 17671.8 17671.8 14726.5 14726.5 E 2121.81 2121.81 humana medicare advantage pos Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 2121.81 2121.81 1025.79 1025.79 17671.8 17671.8 14726.5 14726.5 E 2121.81 2121.81 humana medicare advantage ppo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 2121.81 2121.81 1025.79 1025.79 17671.8 17671.8 14726.5 14726.5 E 2121.81 2121.81 humana medicare advantage hmo CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 humana medicare advantage hmo CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 humana medicare advantage pos CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 humana medicare advantage ppo CT scan of heart with evaluation of blood vessel calcium cpt 75571 69.57 69.57 50 50 60 60 50 50 O 50 50 humana medicare advantage hmo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 273.17 273.17 humana medicare advantage hmo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 273.17 273.17 humana medicare advantage pos Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 273.17 273.17 humana medicare advantage ppo Fluoroscopic and video recorded motion evaluation of swallowing function cpt 92611 358.77 358.77 124.04 124.04 1200.5 1200.5 1000.42 1000.42 O 273.17 273.17 humana medicare advantage hmo "Balloon dilation of narrowed or blocked major coronary artery or branch (accessed through the skin), each additional artery or branch" cpt 92920 13866.64 13866.64 4401.96 4401.96 62794.31 62794.31 52328.59 52328.59 E 4401.96 4401.96 humana medicare advantage hmo "Balloon dilation of narrowed or blocked major coronary artery or branch (accessed through the skin), each additional artery or branch" cpt 92920 13866.64 13866.64 4401.96 4401.96 62794.31 62794.31 52328.59 52328.59 E 4401.96 4401.96 humana medicare advantage pos "Balloon dilation of narrowed or blocked major coronary artery or branch (accessed through the skin), each additional artery or branch" cpt 92920 13866.64 13866.64 4401.96 4401.96 62794.31 62794.31 52328.59 52328.59 E 4401.96 4401.96 humana medicare advantage ppo "Balloon dilation of narrowed or blocked major coronary artery or branch (accessed through the skin), each additional artery or branch" cpt 92920 13866.64 13866.64 4401.96 4401.96 62794.31 62794.31 52328.59 52328.59 E 4401.96 4401.96 humana medicare advantage hmo "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 8777.72 8777.72 humana medicare advantage hmo "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 8777.72 8777.72 humana medicare advantage pos "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 8777.72 8777.72 humana medicare advantage ppo "Ultrasound evaluation of heart blood vessel or graft, initial vessel" cpt 92978 14120.9 14120.9 8630.33 8630.33 84420.37 84420.37 70350.31 70350.31 O 8777.72 8777.72 humana medicare advantage hmo Attempt to restart heart and lungs cpt 92950 2333.86 2333.86 671.16 671.16 3861.56 3861.56 3217.97 3217.97 E 671.16 671.16 humana medicare advantage hmo Attempt to restart heart and lungs cpt 92950 2333.86 2333.86 671.16 671.16 3861.56 3861.56 3217.97 3217.97 E 671.16 671.16 humana medicare advantage pos Attempt to restart heart and lungs cpt 92950 2333.86 2333.86 671.16 671.16 3861.56 3861.56 3217.97 3217.97 E 671.16 671.16 humana medicare advantage ppo Attempt to restart heart and lungs cpt 92950 2333.86 2333.86 671.16 671.16 3861.56 3861.56 3217.97 3217.97 E 671.16 671.16 humana medicare advantage hmo External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 475.24 475.24 humana medicare advantage hmo External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 475.24 475.24 humana medicare advantage pos External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 475.24 475.24 humana medicare advantage ppo External shock to heart to regulate heart beat cpt 92960 1660.63 1660.63 475.24 475.24 4018.85 4018.85 3349.04 3349.04 O 475.24 475.24 humana medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.89 1914.89 humana medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.89 1914.89 humana medicare advantage pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.89 1914.89 humana medicare advantage ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1914.89 1914.89 humana medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 133.77 133.77 humana medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 133.77 133.77 humana medicare advantage pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 133.77 133.77 humana medicare advantage ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 133.77 133.77 humana medicare advantage hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.2 8.2 humana medicare advantage hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.2 8.2 humana medicare advantage pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.2 8.2 humana medicare advantage ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.2 8.2 humana medicare advantage hmo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 161.43 161.43 humana medicare advantage hmo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 161.43 161.43 humana medicare advantage pos X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 161.43 161.43 humana medicare advantage ppo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 161.43 161.43 humana medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 humana medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 humana medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 humana medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 humana medicare advantage hmo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 humana medicare advantage hmo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 humana medicare advantage pos X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 humana medicare advantage ppo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 161.43 161.43 humana medicare advantage hmo complications of treatment without cc/mcc ms-drg 921 4711.5 4711.5 4681.41 4681.41 36520.37 36520.37 30433.64 30433.64 I 4681.41 4681.41 humana medicare advantage hmo complications of treatment without cc/mcc ms-drg 921 4711.5 4711.5 4681.41 4681.41 36520.37 36520.37 30433.64 30433.64 I 4681.41 4681.41 humana medicare advantage pos complications of treatment without cc/mcc ms-drg 921 4711.5 4711.5 4681.41 4681.41 36520.37 36520.37 30433.64 30433.64 I 4681.41 4681.41 humana medicare advantage ppo complications of treatment without cc/mcc ms-drg 921 4711.5 4711.5 4681.41 4681.41 36520.37 36520.37 30433.64 30433.64 I 4681.41 4681.41 humana medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 humana medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 humana medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 humana medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1127.01 1127.01 humana medicare advantage hmo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage hmo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage pos Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage ppo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage hmo Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 161.43 161.43 humana medicare advantage hmo Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 161.43 161.43 humana medicare advantage pos Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 161.43 161.43 humana medicare advantage ppo Imaging for evaluation of swallowing function cpt 74230 337.93 337.93 86.52 86.52 845.88 845.88 704.9 704.9 O 161.43 161.43 humana medicare advantage hmo X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 161.43 161.43 humana medicare advantage hmo X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 161.43 161.43 humana medicare advantage pos X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 161.43 161.43 humana medicare advantage ppo X-ray of esophagus with single contrast cpt 74220 161.43 161.43 106.05 106.05 595.3 595.3 496.08 496.08 O 161.43 161.43 humana medicare advantage hmo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage hmo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage pos "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage ppo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 96.59 96.59 humana medicare advantage hmo MRI scan of abdomen before and after contrast cpt 74183 338.27 338.27 335.57 335.57 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage hmo MRI scan of abdomen before and after contrast cpt 74183 338.27 338.27 335.57 335.57 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage pos MRI scan of abdomen before and after contrast cpt 74183 338.27 338.27 335.57 335.57 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage ppo MRI scan of abdomen before and after contrast cpt 74183 338.27 338.27 335.57 335.57 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage hmo "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 32.11 32.11 humana medicare advantage hmo "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 32.11 32.11 humana medicare advantage pos "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 32.11 32.11 humana medicare advantage ppo "Evaluation, testing, and programming adjustment of permanent dual lead pacemaker system with physician analysis, review, and report" cpt 93280 71.59 71.59 31.6 31.6 245.5 245.5 204.58 204.58 O 32.11 32.11 humana medicare advantage hmo "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, single lead defibrillator system" cpt 93282 61.52 61.52 32.11 32.11 237.86 237.86 198.22 198.22 O 32.11 32.11 humana medicare advantage hmo "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, single lead defibrillator system" cpt 93282 61.52 61.52 32.11 32.11 237.86 237.86 198.22 198.22 O 32.11 32.11 humana medicare advantage pos "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, single lead defibrillator system" cpt 93282 61.52 61.52 32.11 32.11 237.86 237.86 198.22 198.22 O 32.11 32.11 humana medicare advantage ppo "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, single lead defibrillator system" cpt 93282 61.52 61.52 32.11 32.11 237.86 237.86 198.22 198.22 O 32.11 32.11 humana medicare advantage hmo "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system" cpt 93283 32.11 32.11 31.6 31.6 293.83 293.83 244.86 244.86 O 32.11 32.11 humana medicare advantage hmo "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system" cpt 93283 32.11 32.11 31.6 31.6 293.83 293.83 244.86 244.86 O 32.11 32.11 humana medicare advantage pos "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system" cpt 93283 32.11 32.11 31.6 31.6 293.83 293.83 244.86 244.86 O 32.11 32.11 humana medicare advantage ppo "Evaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system" cpt 93283 32.11 32.11 31.6 31.6 293.83 293.83 244.86 244.86 O 32.11 32.11 humana medicare advantage hmo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 humana medicare advantage hmo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 humana medicare advantage pos "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 humana medicare advantage ppo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 32.11 32.11 humana medicare advantage hmo "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 32.11 32.11 humana medicare advantage hmo "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 32.11 32.11 humana medicare advantage pos "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 32.11 32.11 humana medicare advantage ppo "Evaluation of defibrillator including connection, recording and disconnection" cpt 93289 76.59 76.59 31.86 31.86 222.6 222.6 185.5 185.5 O 32.11 32.11 humana medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 humana medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 humana medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 humana medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 1965.52 1965.52 humana medicare advantage hmo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 338.27 338.27 humana medicare advantage hmo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 338.27 338.27 humana medicare advantage pos CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 338.27 338.27 humana medicare advantage ppo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 338.27 338.27 humana medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 humana medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 humana medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 humana medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 humana medicare advantage hmo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 206.45 206.45 humana medicare advantage hmo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 206.45 206.45 humana medicare advantage pos Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 206.45 206.45 humana medicare advantage ppo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 206.45 206.45 humana medicare advantage hmo Insertion of probe in esophagus for heart ultrasound examination including interpretation and report cpt 93312 2524.71 2524.71 426.62 426.62 2675.2 2675.2 2229.33 2229.33 O 1475.67 1475.67 humana medicare advantage hmo Insertion of probe in esophagus for heart ultrasound examination including interpretation and report cpt 93312 2524.71 2524.71 426.62 426.62 2675.2 2675.2 2229.33 2229.33 O 1475.67 1475.67 humana medicare advantage pos Insertion of probe in esophagus for heart ultrasound examination including interpretation and report cpt 93312 2524.71 2524.71 426.62 426.62 2675.2 2675.2 2229.33 2229.33 O 1475.67 1475.67 humana medicare advantage ppo Insertion of probe in esophagus for heart ultrasound examination including interpretation and report cpt 93312 2524.71 2524.71 426.62 426.62 2675.2 2675.2 2229.33 2229.33 O 1475.67 1475.67 humana medicare advantage hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 206.45 206.45 humana medicare advantage hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 206.45 206.45 humana medicare advantage pos CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 206.45 206.45 humana medicare advantage ppo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 206.45 206.45 humana medicare advantage hmo Insertion of catheter into right and left heart for diagnosis cpt 93453 2524.71 2524.71 2524.71 2524.71 18938.18 18938.18 15781.82 15781.82 O 2524.71 2524.71 humana medicare advantage hmo Insertion of catheter into right and left heart for diagnosis cpt 93453 2524.71 2524.71 2524.71 2524.71 18938.18 18938.18 15781.82 15781.82 O 2524.71 2524.71 humana medicare advantage pos Insertion of catheter into right and left heart for diagnosis cpt 93453 2524.71 2524.71 2524.71 2524.71 18938.18 18938.18 15781.82 15781.82 O 2524.71 2524.71 humana medicare advantage ppo Insertion of catheter into right and left heart for diagnosis cpt 93453 2524.71 2524.71 2524.71 2524.71 18938.18 18938.18 15781.82 15781.82 O 2524.71 2524.71 humana medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 3445.85 3445.85 humana medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 3445.85 3445.85 humana medicare advantage pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 3445.85 3445.85 humana medicare advantage ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 3445.85 3445.85 humana medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 humana medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 humana medicare advantage pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 humana medicare advantage ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 humana medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 8777.72 8777.72 humana medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 8777.72 8777.72 humana medicare advantage pos Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 8777.72 8777.72 humana medicare advantage ppo Insertion of catheter in left heart for imaging of blood vessels and/or grafts and left lower heart including imaging interpretation and supervision and injection cpt 93459 8777.72 8777.72 2524.71 2524.71 36788.04 36788.04 30656.7 30656.7 O 8777.72 8777.72 humana medicare advantage hmo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 humana medicare advantage hmo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 humana medicare advantage pos Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 humana medicare advantage ppo Insertion of catheter in right and left heart and left lower heart including imaging interpretation and supervision and injection cpt 93460 2524.71 2524.71 2405.95 2405.95 19303.09 19303.09 16085.91 16085.91 O 2524.71 2524.71 humana medicare advantage hmo Insertion of catheter in right and left heart and left lower heart for imaging of blood vessels and/or grafts including imaging interpretation and supervision and injection cpt 93461 2524.71 2524.71 2524.71 2524.71 24264.78 24264.78 20220.65 20220.65 O 2524.71 2524.71 humana medicare advantage hmo Insertion of catheter in right and left heart and left lower heart for imaging of blood vessels and/or grafts including imaging interpretation and supervision and injection cpt 93461 2524.71 2524.71 2524.71 2524.71 24264.78 24264.78 20220.65 20220.65 O 2524.71 2524.71 humana medicare advantage pos Insertion of catheter in right and left heart and left lower heart for imaging of blood vessels and/or grafts including imaging interpretation and supervision and injection cpt 93461 2524.71 2524.71 2524.71 2524.71 24264.78 24264.78 20220.65 20220.65 O 2524.71 2524.71 humana medicare advantage ppo Insertion of catheter in right and left heart and left lower heart for imaging of blood vessels and/or grafts including imaging interpretation and supervision and injection cpt 93461 2524.71 2524.71 2524.71 2524.71 24264.78 24264.78 20220.65 20220.65 O 2524.71 2524.71 humana medicare advantage hmo Injection for X-ray imaging of aorta above heart valve cpt 93567 2524.71 2524.71 2524.71 2524.71 22959.67 22959.67 19133.06 19133.06 O 2524.71 2524.71 humana medicare advantage hmo Injection for X-ray imaging of aorta above heart valve cpt 93567 2524.71 2524.71 2524.71 2524.71 22959.67 22959.67 19133.06 19133.06 O 2524.71 2524.71 humana medicare advantage pos Injection for X-ray imaging of aorta above heart valve cpt 93567 2524.71 2524.71 2524.71 2524.71 22959.67 22959.67 19133.06 19133.06 O 2524.71 2524.71 humana medicare advantage ppo Injection for X-ray imaging of aorta above heart valve cpt 93567 2524.71 2524.71 2524.71 2524.71 22959.67 22959.67 19133.06 19133.06 O 2524.71 2524.71 humana medicare advantage hmo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 4401.96 4401.96 4388.57 4388.57 51639.92 51639.92 43033.27 43033.27 E 4401.96 4401.96 humana medicare advantage hmo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 4401.96 4401.96 4388.57 4388.57 51639.92 51639.92 43033.27 43033.27 E 4401.96 4401.96 humana medicare advantage pos "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 4401.96 4401.96 4388.57 4388.57 51639.92 51639.92 43033.27 43033.27 E 4401.96 4401.96 humana medicare advantage ppo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, initial vessel" cpt 93571 4401.96 4401.96 4388.57 4388.57 51639.92 51639.92 43033.27 43033.27 E 4401.96 4401.96 humana medicare advantage hmo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 206.45 206.45 humana medicare advantage hmo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 206.45 206.45 humana medicare advantage pos CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 206.45 206.45 humana medicare advantage ppo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 206.45 206.45 humana medicare advantage hmo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, each additional vessel" cpt 93572 4401.96 4401.96 4388.57 4388.57 51044.06 51044.06 42536.72 42536.72 E 4401.96 4401.96 humana medicare advantage hmo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, each additional vessel" cpt 93572 4401.96 4401.96 4388.57 4388.57 51044.06 51044.06 42536.72 42536.72 E 4401.96 4401.96 humana medicare advantage pos "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, each additional vessel" cpt 93572 4401.96 4401.96 4388.57 4388.57 51044.06 51044.06 42536.72 42536.72 E 4401.96 4401.96 humana medicare advantage ppo "Ultrasound evaluation of heart blood vessel during diagnosis or treatment, each additional vessel" cpt 93572 4401.96 4401.96 4388.57 4388.57 51044.06 51044.06 42536.72 42536.72 E 4401.96 4401.96 humana medicare advantage hmo CT scan of abdominal blood vessels with contrast cpt 74175 161.43 161.43 161.43 161.43 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage hmo CT scan of abdominal blood vessels with contrast cpt 74175 161.43 161.43 161.43 161.43 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage pos CT scan of abdominal blood vessels with contrast cpt 74175 161.43 161.43 161.43 161.43 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage ppo CT scan of abdominal blood vessels with contrast cpt 74175 161.43 161.43 161.43 161.43 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage hmo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 338.27 338.27 humana medicare advantage hmo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 338.27 338.27 humana medicare advantage pos CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 338.27 338.27 humana medicare advantage ppo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 632.1 632.1 332.86 332.86 1872.38 1872.38 1560.32 1560.32 O 338.27 338.27 humana medicare advantage hmo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 754.26 754.26 242.37 242.37 1872.38 1872.38 1560.32 1560.32 E 754.26 754.26 humana medicare advantage hmo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 754.26 754.26 242.37 242.37 1872.38 1872.38 1560.32 1560.32 E 754.26 754.26 humana medicare advantage pos CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 754.26 754.26 242.37 242.37 1872.38 1872.38 1560.32 1560.32 E 754.26 754.26 humana medicare advantage ppo CT scan of abdominal and pelvic blood vessels with contrast cpt 74174 754.26 754.26 242.37 242.37 1872.38 1872.38 1560.32 1560.32 E 754.26 754.26 humana medicare advantage hmo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 877.23 877.23 humana medicare advantage hmo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 877.23 877.23 humana medicare advantage pos Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 877.23 877.23 humana medicare advantage ppo Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session cpt 93798 1250 1250 479.55 479.55 1591.92 1591.92 1326.6 1326.6 O 877.23 877.23 humana medicare advantage hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 90 90 humana medicare advantage hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 90 90 humana medicare advantage pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 90 90 humana medicare advantage ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 90 90 humana medicare advantage hmo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 161.43 161.43 humana medicare advantage hmo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 161.43 161.43 humana medicare advantage pos CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 161.43 161.43 humana medicare advantage ppo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 161.43 161.43 humana medicare advantage hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 206.45 206.45 humana medicare advantage hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 206.45 206.45 humana medicare advantage pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 206.45 206.45 humana medicare advantage ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 206.45 206.45 humana medicare advantage hmo "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 96.08 96.08 humana medicare advantage hmo "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 96.08 96.08 humana medicare advantage pos "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 96.08 96.08 humana medicare advantage ppo "Ultrasound study of arteries of both arms and legs, limited" cpt 93922 286.66 286.66 88.23 88.23 419.76 419.76 349.8 349.8 O 96.08 96.08 humana medicare advantage hmo CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage hmo CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage pos CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage ppo CT scan abdomen cpt 74150 592.16 592.16 86.75 86.75 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage pos Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage ppo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 99.29 99.29 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 99.29 99.29 humana medicare advantage pos Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 99.29 99.29 humana medicare advantage ppo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 99.29 99.29 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 humana medicare advantage pos Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 humana medicare advantage ppo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 99.29 99.29 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage hmo Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage pos Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage ppo Ultrasound study of arteries and arterial grafts of both arms cpt 93930 282.79 282.79 206.45 206.45 783.55 783.55 652.96 652.96 O 206.45 206.45 humana medicare advantage hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 206.45 206.45 humana medicare advantage hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 206.45 206.45 humana medicare advantage pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 206.45 206.45 humana medicare advantage ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 573.24 573.24 136.54 136.54 1129.54 1129.54 941.28 941.28 E 206.45 206.45 humana medicare advantage hmo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 99.29 99.29 humana medicare advantage hmo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 99.29 99.29 humana medicare advantage pos "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 99.29 99.29 humana medicare advantage ppo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 99.29 99.29 humana medicare advantage hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 humana medicare advantage hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 humana medicare advantage pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 humana medicare advantage ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 humana medicare advantage hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 99.29 99.29 humana medicare advantage hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 99.29 99.29 humana medicare advantage pos Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 99.29 99.29 humana medicare advantage ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 99.29 99.29 humana medicare advantage hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 99.29 99.29 humana medicare advantage hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 99.29 99.29 humana medicare advantage pos Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 99.29 99.29 humana medicare advantage ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 99.29 99.29 humana medicare advantage hmo "X-ray of abdomen, 2 views" cpt 74019 99.29 99.29 20.35 20.35 380.71 380.71 317.26 317.26 O 99.29 99.29 humana medicare advantage hmo "X-ray of abdomen, 2 views" cpt 74019 99.29 99.29 20.35 20.35 380.71 380.71 317.26 317.26 O 99.29 99.29 humana medicare advantage pos "X-ray of abdomen, 2 views" cpt 74019 99.29 99.29 20.35 20.35 380.71 380.71 317.26 317.26 O 99.29 99.29 humana medicare advantage ppo "X-ray of abdomen, 2 views" cpt 74019 99.29 99.29 20.35 20.35 380.71 380.71 317.26 317.26 O 99.29 99.29 humana medicare advantage hmo "Ventilation assistance and management, hospital inpatient or observation, initial day" cpt 94002 1466.26 1466.26 1199.26 1199.26 13744.27 13744.27 11453.56 11453.56 O 1466.26 1466.26 humana medicare advantage hmo "Ventilation assistance and management, hospital inpatient or observation, initial day" cpt 94002 1466.26 1466.26 1199.26 1199.26 13744.27 13744.27 11453.56 11453.56 O 1466.26 1466.26 humana medicare advantage pos "Ventilation assistance and management, hospital inpatient or observation, initial day" cpt 94002 1466.26 1466.26 1199.26 1199.26 13744.27 13744.27 11453.56 11453.56 O 1466.26 1466.26 humana medicare advantage ppo "Ventilation assistance and management, hospital inpatient or observation, initial day" cpt 94002 1466.26 1466.26 1199.26 1199.26 13744.27 13744.27 11453.56 11453.56 O 1466.26 1466.26 humana medicare advantage hmo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 224.22 224.22 humana medicare advantage hmo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 224.22 224.22 humana medicare advantage pos Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 224.22 224.22 humana medicare advantage ppo Measurement and graphic recording of total and timed exhaled air capacity cpt 94010 608.56 608.56 122.56 122.56 501.17 501.17 417.64 417.64 O 224.22 224.22 humana medicare advantage hmo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 224.22 224.22 humana medicare advantage hmo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 224.22 224.22 humana medicare advantage pos "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 224.22 224.22 humana medicare advantage ppo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 224.22 224.22 humana medicare advantage hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 humana medicare advantage hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 humana medicare advantage pos "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 humana medicare advantage ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 humana medicare advantage hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 humana medicare advantage hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 humana medicare advantage pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 humana medicare advantage ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1952.13 1952.13 humana medicare advantage hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 1523.14 1523.14 humana medicare advantage hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 1523.14 1523.14 humana medicare advantage pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 1523.14 1523.14 humana medicare advantage ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 1523.14 1523.14 humana medicare advantage hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1914.89 1914.89 humana medicare advantage hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1914.89 1914.89 humana medicare advantage pos Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1914.89 1914.89 humana medicare advantage ppo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 1914.89 1914.89 humana medicare advantage hmo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 338.27 338.27 humana medicare advantage hmo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 338.27 338.27 humana medicare advantage pos MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 338.27 338.27 humana medicare advantage ppo MRI scan of leg joint before and after contrast cpt 73723 1807.46 1807.46 338.27 338.27 3531.07 3531.07 2942.56 2942.56 O 338.27 338.27 humana medicare advantage hmo Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1914.89 1914.89 humana medicare advantage hmo Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1914.89 1914.89 humana medicare advantage pos Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1914.89 1914.89 humana medicare advantage ppo Initiation and management of continued pressured respiratory assistance by mask or breathing tube cpt 94660 1995.04 1995.04 404.51 404.51 12147.43 12147.43 10122.86 10122.86 E 1914.89 1914.89 humana medicare advantage hmo "Demonstration and/or evaluation of patient use of aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device" cpt 94664 2121.81 2121.81 216.25 216.25 2288.58 2288.58 1907.15 1907.15 E 2121.81 2121.81 humana medicare advantage hmo "Demonstration and/or evaluation of patient use of aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device" cpt 94664 2121.81 2121.81 216.25 216.25 2288.58 2288.58 1907.15 1907.15 E 2121.81 2121.81 humana medicare advantage pos "Demonstration and/or evaluation of patient use of aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device" cpt 94664 2121.81 2121.81 216.25 216.25 2288.58 2288.58 1907.15 1907.15 E 2121.81 2121.81 humana medicare advantage ppo "Demonstration and/or evaluation of patient use of aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device" cpt 94664 2121.81 2121.81 216.25 216.25 2288.58 2288.58 1907.15 1907.15 E 2121.81 2121.81 humana medicare advantage hmo Manual maneuvers to chest wall to assist movement of lung secretions cpt 94668 2485.45 2485.45 1462.18 1462.18 21306.34 21306.34 17755.28 17755.28 E 1462.18 1462.18 humana medicare advantage hmo Manual maneuvers to chest wall to assist movement of lung secretions cpt 94668 2485.45 2485.45 1462.18 1462.18 21306.34 21306.34 17755.28 17755.28 E 1462.18 1462.18 humana medicare advantage pos Manual maneuvers to chest wall to assist movement of lung secretions cpt 94668 2485.45 2485.45 1462.18 1462.18 21306.34 21306.34 17755.28 17755.28 E 1462.18 1462.18 humana medicare advantage ppo Manual maneuvers to chest wall to assist movement of lung secretions cpt 94668 2485.45 2485.45 1462.18 1462.18 21306.34 21306.34 17755.28 17755.28 E 1462.18 1462.18 humana medicare advantage hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage pos Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage ppo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage hmo MRI scan of leg before and after contrast cpt 73720 338.27 338.27 245.38 245.38 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 humana medicare advantage hmo MRI scan of leg before and after contrast cpt 73720 338.27 338.27 245.38 245.38 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 humana medicare advantage pos MRI scan of leg before and after contrast cpt 73720 338.27 338.27 245.38 245.38 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 humana medicare advantage ppo MRI scan of leg before and after contrast cpt 73720 338.27 338.27 245.38 245.38 3107.5 3107.5 2589.58 2589.58 O 338.27 338.27 humana medicare advantage hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage pos Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage ppo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 224.22 224.22 humana medicare advantage hmo Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1952.13 1952.13 humana medicare advantage hmo Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1952.13 1952.13 humana medicare advantage pos Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1952.13 1952.13 humana medicare advantage ppo Pulmonary service or operation cpt 94799 1995.04 1995.04 716.79 716.79 15027.26 15027.26 12522.72 12522.72 E 1952.13 1952.13 humana medicare advantage hmo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 humana medicare advantage hmo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 humana medicare advantage pos CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 humana medicare advantage ppo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 humana medicare advantage hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 805.22 805.22 humana medicare advantage hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 805.22 805.22 humana medicare advantage pos Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 805.22 805.22 humana medicare advantage ppo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 805.22 805.22 humana medicare advantage hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 121.34 121.34 humana medicare advantage hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 121.34 121.34 humana medicare advantage pos "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 121.34 121.34 humana medicare advantage ppo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 121.34 121.34 humana medicare advantage hmo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 2034.24 2034.24 1892.2 1892.2 17941.79 17941.79 14951.49 14951.49 E 2034.24 2034.24 humana medicare advantage hmo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 2034.24 2034.24 1892.2 1892.2 17941.79 17941.79 14951.49 14951.49 E 2034.24 2034.24 humana medicare advantage pos "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 2034.24 2034.24 1892.2 1892.2 17941.79 17941.79 14951.49 14951.49 E 2034.24 2034.24 humana medicare advantage ppo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 2034.24 2034.24 1892.2 1892.2 17941.79 17941.79 14951.49 14951.49 E 2034.24 2034.24 humana medicare advantage hmo CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 98.3 98.3 humana medicare advantage hmo CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 98.3 98.3 humana medicare advantage pos CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 98.3 98.3 humana medicare advantage ppo CT scan leg cpt 73700 739.85 739.85 93.83 93.83 1504.78 1504.78 1253.98 1253.98 E 98.3 98.3 humana medicare advantage hmo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 222.88 222.88 humana medicare advantage hmo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 222.88 222.88 humana medicare advantage pos "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 222.88 222.88 humana medicare advantage ppo "Measurement and recording of brain wave (EEG) activity, awake and asleep" cpt 95819 1179.83 1179.83 222.88 222.88 840.79 840.79 700.66 700.66 O 222.88 222.88 humana medicare advantage hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 837.93 837.93 humana medicare advantage hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 837.93 837.93 humana medicare advantage pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 837.93 837.93 humana medicare advantage ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 837.93 837.93 humana medicare advantage hmo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage hmo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage pos "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage ppo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 601.12 601.12 humana medicare advantage hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 601.12 601.12 humana medicare advantage pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 601.12 601.12 humana medicare advantage ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 601.12 601.12 humana medicare advantage hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 926.03 926.03 humana medicare advantage hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 926.03 926.03 humana medicare advantage pos Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 926.03 926.03 humana medicare advantage ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 926.03 926.03 humana medicare advantage hmo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 2742.85 2742.85 humana medicare advantage hmo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 2742.85 2742.85 humana medicare advantage pos Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 2742.85 2742.85 humana medicare advantage ppo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 2742.85 2742.85 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1914.89 1914.89 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1914.89 1914.89 humana medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1914.89 1914.89 humana medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1914.89 1914.89 humana medicare advantage hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.7 70.7 humana medicare advantage hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.7 70.7 humana medicare advantage pos "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.7 70.7 humana medicare advantage ppo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 70.7 70.7 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 763.52 763.52 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 763.52 763.52 humana medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 763.52 763.52 humana medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 763.52 763.52 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1952.13 1952.13 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1952.13 1952.13 humana medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1952.13 1952.13 humana medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 1952.13 1952.13 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 2332.81 2332.81 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 2332.81 2332.81 humana medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 2332.81 2332.81 humana medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 2332.81 2332.81 humana medicare advantage hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 1952.13 1952.13 655.54 655.54 8924.22 8924.22 7436.85 7436.85 E 1952.13 1952.13 humana medicare advantage hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 1952.13 1952.13 655.54 655.54 8924.22 8924.22 7436.85 7436.85 E 1952.13 1952.13 humana medicare advantage pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 1952.13 1952.13 655.54 655.54 8924.22 8924.22 7436.85 7436.85 E 1952.13 1952.13 humana medicare advantage ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 1952.13 1952.13 655.54 655.54 8924.22 8924.22 7436.85 7436.85 E 1952.13 1952.13 humana medicare advantage hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 3984.02 3984.02 humana medicare advantage hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 3984.02 3984.02 humana medicare advantage pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 3984.02 3984.02 humana medicare advantage ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 3984.02 3984.02 humana medicare advantage hmo "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage hmo "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage pos "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage ppo "X-ray of foot, 2 views" cpt 73620 70.7 70.7 16.76 16.76 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 1462.18 1462.18 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 1462.18 1462.18 humana medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 1462.18 1462.18 humana medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 1462.18 1462.18 humana medicare advantage hmo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage hmo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage pos "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage ppo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 977.57 977.57 humana medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 977.57 977.57 humana medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 977.57 977.57 humana medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 5988.6 5988.6 977.57 977.57 18431.28 18431.28 15359.4 15359.4 O 977.57 977.57 humana medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 humana medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 humana medicare advantage pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 humana medicare advantage ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1952.13 1952.13 humana medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 humana medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 humana medicare advantage pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 humana medicare advantage ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 humana medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 947.72 947.72 humana medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 947.72 947.72 humana medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 947.72 947.72 humana medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 947.72 947.72 humana medicare advantage hmo "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage hmo "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage pos "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage ppo "X-ray of lower leg, 2 views" cpt 73590 197.67 197.67 18.86 18.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 3069.64 3069.64 humana medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 3069.64 3069.64 humana medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 3069.64 3069.64 humana medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 3069.64 3069.64 humana medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 humana medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 humana medicare advantage pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 humana medicare advantage ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1952.13 1952.13 humana medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4309.68 4309.68 humana medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4309.68 4309.68 humana medicare advantage pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4309.68 4309.68 humana medicare advantage ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4309.68 4309.68 humana medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1965.52 1965.52 humana medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1965.52 1965.52 humana medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1965.52 1965.52 humana medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1965.52 1965.52 humana medicare advantage hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 99.29 99.29 humana medicare advantage hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 99.29 99.29 humana medicare advantage pos "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 99.29 99.29 humana medicare advantage ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 99.29 99.29 humana medicare advantage hmo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 10727.89 10727.89 humana medicare advantage hmo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 10727.89 10727.89 humana medicare advantage pos Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 10727.89 10727.89 humana medicare advantage ppo Application of on-body injector for injection under skin cpt 96377 13222.87 13222.87 6746.76 6746.76 42194.78 42194.78 35162.32 35162.32 O 10727.89 10727.89 humana medicare advantage hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 1204.76 1204.76 humana medicare advantage hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 1204.76 1204.76 humana medicare advantage pos Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 1204.76 1204.76 humana medicare advantage ppo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 1204.76 1204.76 humana medicare advantage hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 800.92 800.92 humana medicare advantage hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 800.92 800.92 humana medicare advantage pos Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 800.92 800.92 humana medicare advantage ppo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 800.92 800.92 humana medicare advantage hmo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 7692.75 7692.75 humana medicare advantage hmo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 7692.75 7692.75 humana medicare advantage pos Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 7692.75 7692.75 humana medicare advantage ppo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 7692.75 7692.75 humana medicare advantage hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage pos "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage ppo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 977.57 977.57 humana medicare advantage hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 977.57 977.57 humana medicare advantage pos Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 977.57 977.57 humana medicare advantage ppo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 977.57 977.57 humana medicare advantage hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 5404.77 5404.77 humana medicare advantage hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 5404.77 5404.77 humana medicare advantage pos Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 5404.77 5404.77 humana medicare advantage ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 5404.77 5404.77 humana medicare advantage hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4235.47 4235.47 humana medicare advantage hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4235.47 4235.47 humana medicare advantage pos Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4235.47 4235.47 humana medicare advantage ppo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 4235.47 4235.47 humana medicare advantage hmo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage hmo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage pos "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage ppo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage hmo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 70.7 70.7 humana medicare advantage hmo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 70.7 70.7 humana medicare advantage pos "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 70.7 70.7 humana medicare advantage ppo "X-ray of femur, minimum 2 views" cpt 73552 163.85 163.85 21.25 21.25 314.4 314.4 262 262 O 70.7 70.7 humana medicare advantage hmo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 957.13 957.13 humana medicare advantage hmo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 957.13 957.13 humana medicare advantage pos Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 957.13 957.13 humana medicare advantage ppo Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours cpt 96416 8184.57 8184.57 957.13 957.13 19972.8 19972.8 16644 16644 O 957.13 957.13 humana medicare advantage hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5391.96 5391.96 humana medicare advantage hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5391.96 5391.96 humana medicare advantage pos Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5391.96 5391.96 humana medicare advantage ppo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 5391.96 5391.96 humana medicare advantage hmo Radiological supervision and interpretation X-ray of hip joint cpt 73525 338.27 338.27 332.86 332.86 1232.57 1232.57 1027.14 1027.14 O 338.27 338.27 humana medicare advantage hmo Radiological supervision and interpretation X-ray of hip joint cpt 73525 338.27 338.27 332.86 332.86 1232.57 1232.57 1027.14 1027.14 O 338.27 338.27 humana medicare advantage pos Radiological supervision and interpretation X-ray of hip joint cpt 73525 338.27 338.27 332.86 332.86 1232.57 1232.57 1027.14 1027.14 O 338.27 338.27 humana medicare advantage ppo Radiological supervision and interpretation X-ray of hip joint cpt 73525 338.27 338.27 332.86 332.86 1232.57 1232.57 1027.14 1027.14 O 338.27 338.27 humana medicare advantage hmo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 99.29 99.29 humana medicare advantage hmo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 99.29 99.29 humana medicare advantage pos "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 99.29 99.29 humana medicare advantage ppo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 99.29 99.29 humana medicare advantage hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage pos Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage hmo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 496.33 496.33 humana medicare advantage hmo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 496.33 496.33 humana medicare advantage pos Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 496.33 496.33 humana medicare advantage ppo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 496.33 496.33 humana medicare advantage hmo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 99.29 99.29 97.3 97.3 727.58 727.58 606.32 606.32 E 97.3 97.3 humana medicare advantage hmo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 99.29 99.29 97.3 97.3 727.58 727.58 606.32 606.32 E 97.3 97.3 humana medicare advantage pos "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 99.29 99.29 97.3 97.3 727.58 727.58 606.32 606.32 E 97.3 97.3 humana medicare advantage ppo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 99.29 99.29 97.3 97.3 727.58 727.58 606.32 606.32 E 97.3 97.3 humana medicare advantage hmo "Application of electrical stimulation to 1 or more areas, each 15 minutes" cpt 97032 421.07 421.07 14.45 14.45 9230.88 9230.88 7692.4 7692.4 O 421.07 421.07 humana medicare advantage hmo "Application of electrical stimulation to 1 or more areas, each 15 minutes" cpt 97032 421.07 421.07 14.45 14.45 9230.88 9230.88 7692.4 7692.4 O 421.07 421.07 humana medicare advantage pos "Application of electrical stimulation to 1 or more areas, each 15 minutes" cpt 97032 421.07 421.07 14.45 14.45 9230.88 9230.88 7692.4 7692.4 O 421.07 421.07 humana medicare advantage ppo "Application of electrical stimulation to 1 or more areas, each 15 minutes" cpt 97032 421.07 421.07 14.45 14.45 9230.88 9230.88 7692.4 7692.4 O 421.07 421.07 humana medicare advantage hmo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 496.33 496.33 humana medicare advantage hmo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 496.33 496.33 humana medicare advantage pos "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 496.33 496.33 humana medicare advantage ppo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 496.33 496.33 humana medicare advantage hmo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 626.66 626.66 humana medicare advantage hmo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 626.66 626.66 humana medicare advantage pos "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 626.66 626.66 humana medicare advantage ppo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 626.66 626.66 humana medicare advantage hmo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 670.65 670.65 humana medicare advantage hmo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 670.65 670.65 humana medicare advantage pos "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 670.65 670.65 humana medicare advantage ppo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 670.65 670.65 humana medicare advantage hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3069.09 3069.09 2002.28 2002.28 49620.42 49620.42 41350.35 41350.35 E 3069.09 3069.09 humana medicare advantage hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3069.09 3069.09 2002.28 2002.28 49620.42 49620.42 41350.35 41350.35 E 3069.09 3069.09 humana medicare advantage pos "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3069.09 3069.09 2002.28 2002.28 49620.42 49620.42 41350.35 41350.35 E 3069.09 3069.09 humana medicare advantage ppo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3069.09 3069.09 2002.28 2002.28 49620.42 49620.42 41350.35 41350.35 E 3069.09 3069.09 humana medicare advantage hmo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 70.7 70.7 humana medicare advantage hmo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 70.7 70.7 humana medicare advantage pos "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 70.7 70.7 humana medicare advantage ppo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 70.7 70.7 humana medicare advantage hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 600.02 600.02 humana medicare advantage hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 600.02 600.02 humana medicare advantage pos "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 600.02 600.02 humana medicare advantage ppo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 600.02 600.02 humana medicare advantage hmo MRI scan of arm joint before and after contrast cpt 73223 338.27 338.27 338.27 338.27 3431.14 3431.14 2859.28 2859.28 O 338.27 338.27 humana medicare advantage hmo MRI scan of arm joint before and after contrast cpt 73223 338.27 338.27 338.27 338.27 3431.14 3431.14 2859.28 2859.28 O 338.27 338.27 humana medicare advantage pos MRI scan of arm joint before and after contrast cpt 73223 338.27 338.27 338.27 338.27 3431.14 3431.14 2859.28 2859.28 O 338.27 338.27 humana medicare advantage ppo MRI scan of arm joint before and after contrast cpt 73223 338.27 338.27 338.27 338.27 3431.14 3431.14 2859.28 2859.28 O 338.27 338.27 humana medicare advantage hmo MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 603.12 603.12 humana medicare advantage hmo MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 603.12 603.12 humana medicare advantage pos MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 603.12 603.12 humana medicare advantage ppo MRI scan of arm joint with contrast cpt 73222 891.88 891.88 603.12 603.12 3107.5 3107.5 2589.58 2589.58 O 603.12 603.12 humana medicare advantage hmo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 641.96 641.96 humana medicare advantage hmo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 641.96 641.96 humana medicare advantage pos "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 641.96 641.96 humana medicare advantage ppo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 641.96 641.96 humana medicare advantage hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2121.81 2121.81 2052.62 2052.62 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2121.81 2121.81 2052.62 2052.62 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage pos "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2121.81 2121.81 2052.62 2052.62 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage ppo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2121.81 2121.81 2052.62 2052.62 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage pos MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 468.06 468.06 humana medicare advantage hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 468.06 468.06 humana medicare advantage pos "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 468.06 468.06 humana medicare advantage ppo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 468.06 468.06 humana medicare advantage hmo "Self-care or home management training, each 15 minutes" cpt 97535 2121.81 2121.81 2102.95 2102.95 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage hmo "Self-care or home management training, each 15 minutes" cpt 97535 2121.81 2121.81 2102.95 2102.95 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage pos "Self-care or home management training, each 15 minutes" cpt 97535 2121.81 2121.81 2102.95 2102.95 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage ppo "Self-care or home management training, each 15 minutes" cpt 97535 2121.81 2121.81 2102.95 2102.95 32128.06 32128.06 26773.38 26773.38 E 2121.81 2121.81 humana medicare advantage hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2136.63 2136.63 2034.73 2034.73 15002.65 15002.65 12502.21 12502.21 E 2034.73 2034.73 humana medicare advantage hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2136.63 2136.63 2034.73 2034.73 15002.65 15002.65 12502.21 12502.21 E 2034.73 2034.73 humana medicare advantage pos "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2136.63 2136.63 2034.73 2034.73 15002.65 15002.65 12502.21 12502.21 E 2034.73 2034.73 humana medicare advantage ppo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2136.63 2136.63 2034.73 2034.73 15002.65 15002.65 12502.21 12502.21 E 2034.73 2034.73 humana medicare advantage hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 426.92 426.92 humana medicare advantage hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 426.92 426.92 humana medicare advantage pos "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 426.92 426.92 humana medicare advantage ppo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 426.92 426.92 humana medicare advantage hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2102.95 2102.95 humana medicare advantage hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2102.95 2102.95 humana medicare advantage pos "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2102.95 2102.95 humana medicare advantage ppo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2102.95 2102.95 humana medicare advantage hmo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage pos MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage ppo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 288.39 288.39 humana medicare advantage hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 288.39 288.39 humana medicare advantage pos "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 288.39 288.39 humana medicare advantage ppo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 288.39 288.39 humana medicare advantage hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2102.95 2102.95 humana medicare advantage hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2102.95 2102.95 humana medicare advantage pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2102.95 2102.95 humana medicare advantage ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2102.95 2102.95 humana medicare advantage hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 290.36 290.36 humana medicare advantage hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 290.36 290.36 humana medicare advantage pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 290.36 290.36 humana medicare advantage ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 290.36 290.36 humana medicare advantage hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 2121.81 2121.81 2052.6 2052.6 19215.01 19215.01 16012.51 16012.51 E 2121.81 2121.81 humana medicare advantage hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 2121.81 2121.81 2052.6 2052.6 19215.01 19215.01 16012.51 16012.51 E 2121.81 2121.81 humana medicare advantage pos "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 2121.81 2121.81 2052.6 2052.6 19215.01 19215.01 16012.51 16012.51 E 2121.81 2121.81 humana medicare advantage ppo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 2121.81 2121.81 2052.6 2052.6 19215.01 19215.01 16012.51 16012.51 E 2121.81 2121.81 humana medicare advantage hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 369.79 369.79 humana medicare advantage hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 369.79 369.79 humana medicare advantage pos "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 369.79 369.79 humana medicare advantage ppo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 369.79 369.79 humana medicare advantage hmo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage hmo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage pos CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage ppo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2102.95 2102.95 humana medicare advantage hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2102.95 2102.95 humana medicare advantage pos "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2102.95 2102.95 humana medicare advantage ppo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2102.95 2102.95 humana medicare advantage hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 421.07 421.07 humana medicare advantage hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 421.07 421.07 humana medicare advantage pos "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 421.07 421.07 humana medicare advantage ppo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 1099.17 1099.17 362.14 362.14 2913.61 2913.61 2428.01 2428.01 O 421.07 421.07 humana medicare advantage hmo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage hmo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage pos "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage ppo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 70.7 70.7 humana medicare advantage hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 humana medicare advantage hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 humana medicare advantage pos "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 humana medicare advantage ppo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 154.79 154.79 humana medicare advantage hmo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 humana medicare advantage hmo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 humana medicare advantage pos "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 humana medicare advantage ppo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 154.79 154.79 humana medicare advantage hmo Negative pressure wound therapy surface area less than or equal to 50 square centimeters per session cpt 97607 581.83 581.83 258.55 258.55 3116.82 3116.82 2597.35 2597.35 O 581.83 581.83 humana medicare advantage hmo Negative pressure wound therapy surface area less than or equal to 50 square centimeters per session cpt 97607 581.83 581.83 258.55 258.55 3116.82 3116.82 2597.35 2597.35 O 581.83 581.83 humana medicare advantage pos Negative pressure wound therapy surface area less than or equal to 50 square centimeters per session cpt 97607 581.83 581.83 258.55 258.55 3116.82 3116.82 2597.35 2597.35 O 581.83 581.83 humana medicare advantage ppo Negative pressure wound therapy surface area less than or equal to 50 square centimeters per session cpt 97607 581.83 581.83 258.55 258.55 3116.82 3116.82 2597.35 2597.35 O 581.83 581.83 humana medicare advantage hmo "Medical nutrition therapy, assessment and intervention, each 15 minutes" cpt 97802 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage hmo "Medical nutrition therapy, assessment and intervention, each 15 minutes" cpt 97802 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage pos "Medical nutrition therapy, assessment and intervention, each 15 minutes" cpt 97802 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage ppo "Medical nutrition therapy, assessment and intervention, each 15 minutes" cpt 97802 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage hmo "Medical nutrition therapy re-assessment and intervention, each 15 minutes" cpt 97803 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage hmo "Medical nutrition therapy re-assessment and intervention, each 15 minutes" cpt 97803 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage pos "Medical nutrition therapy re-assessment and intervention, each 15 minutes" cpt 97803 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage ppo "Medical nutrition therapy re-assessment and intervention, each 15 minutes" cpt 97803 8113.12 8113.12 1959.82 1959.82 27273.68 27273.68 22728.07 22728.07 E 1959.82 1959.82 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 6589.84 6589.84 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 6589.84 6589.84 humana medicare advantage pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 6589.84 6589.84 humana medicare advantage ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 6589.84 6589.84 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2531.41 2531.41 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2531.41 2531.41 humana medicare advantage pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2531.41 2531.41 humana medicare advantage ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 2531.41 2531.41 humana medicare advantage hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage pos "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage ppo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 70.7 70.7 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 8791.16 8791.16 1723.62 1723.62 51580.72 51580.72 42983.93 42983.93 E 6589.84 6589.84 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 8791.16 8791.16 1723.62 1723.62 51580.72 51580.72 42983.93 42983.93 E 6589.84 6589.84 humana medicare advantage pos "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 8791.16 8791.16 1723.62 1723.62 51580.72 51580.72 42983.93 42983.93 E 6589.84 6589.84 humana medicare advantage ppo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 8791.16 8791.16 1723.62 1723.62 51580.72 51580.72 42983.93 42983.93 E 6589.84 6589.84 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2524.71 2524.71 humana medicare advantage hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2524.71 2524.71 humana medicare advantage pos "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2524.71 2524.71 humana medicare advantage ppo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 2524.71 2524.71 humana medicare advantage hmo "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 97.7 97.7 humana medicare advantage hmo "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 97.7 97.7 humana medicare advantage pos "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 97.7 97.7 humana medicare advantage ppo "X-ray of hand, 2 views" cpt 73120 99.29 99.29 18.26 18.26 221.7 221.7 184.75 184.75 O 97.7 97.7 humana medicare advantage hmo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage hmo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage pos "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage ppo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage hmo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage hmo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage pos "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage ppo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 70.7 70.7 humana medicare advantage hmo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 113.36 113.36 humana medicare advantage hmo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 113.36 113.36 humana medicare advantage pos "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 113.36 113.36 humana medicare advantage ppo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 113.36 113.36 humana medicare advantage hmo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 65.75 65.75 humana medicare advantage hmo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 65.75 65.75 humana medicare advantage pos "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 65.75 65.75 humana medicare advantage ppo "X-ray of forearm, 2 views" cpt 73090 127.09 127.09 17.06 17.06 249.31 249.31 207.76 207.76 O 65.75 65.75 humana medicare advantage hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 humana medicare advantage hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 humana medicare advantage pos "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 humana medicare advantage ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 humana medicare advantage hmo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 humana medicare advantage hmo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 humana medicare advantage pos "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 humana medicare advantage ppo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 70.7 70.7 humana medicare advantage hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 846.44 846.44 humana medicare advantage hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 846.44 846.44 humana medicare advantage pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 846.44 846.44 humana medicare advantage ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 846.44 846.44 humana medicare advantage hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 humana medicare advantage hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 humana medicare advantage pos "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 humana medicare advantage ppo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 humana medicare advantage hmo "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage hmo "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage pos "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage ppo "X-ray of elbow, 2 views" cpt 73070 141.16 141.16 16.76 16.76 116 116 96.67 96.67 O 70.7 70.7 humana medicare advantage hmo "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage hmo "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage pos "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage ppo "X-ray of upper arm, minimum of 2 views" cpt 73060 128.03 128.03 18.36 18.36 249.31 249.31 207.76 207.76 O 70.7 70.7 humana medicare advantage hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1466.26 1466.26 humana medicare advantage hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1466.26 1466.26 humana medicare advantage pos "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1466.26 1466.26 humana medicare advantage ppo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1466.26 1466.26 humana medicare advantage hmo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 338.27 338.27 humana medicare advantage hmo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 338.27 338.27 humana medicare advantage pos Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 338.27 338.27 humana medicare advantage ppo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 338.27 338.27 humana medicare advantage hmo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 humana medicare advantage hmo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 humana medicare advantage pos Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 humana medicare advantage ppo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 4282.09 4282.09 humana medicare advantage hmo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 humana medicare advantage hmo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 humana medicare advantage pos Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 humana medicare advantage ppo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 humana medicare advantage hmo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 553.72 553.72 humana medicare advantage hmo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 553.72 553.72 humana medicare advantage pos Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 553.72 553.72 humana medicare advantage ppo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 553.72 553.72 humana medicare advantage hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 70.7 70.7 humana medicare advantage hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 70.7 70.7 humana medicare advantage pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 70.7 70.7 humana medicare advantage ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 70.7 70.7 humana medicare advantage hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1079.07 1079.07 humana medicare advantage hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1079.07 1079.07 humana medicare advantage pos "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1079.07 1079.07 humana medicare advantage ppo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 1079.07 1079.07 humana medicare advantage hmo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 1791.13 1791.13 humana medicare advantage hmo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 1791.13 1791.13 humana medicare advantage pos "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 1791.13 1791.13 humana medicare advantage ppo "Removal of cataract with insertion of lens, simple" cpt 66984 7851.31 7851.31 1636.08 1636.08 14699.72 14699.72 12249.77 12249.77 O 1791.13 1791.13 humana medicare advantage hmo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 805.22 805.22 humana medicare advantage hmo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 805.22 805.22 humana medicare advantage pos Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 805.22 805.22 humana medicare advantage ppo Sleep monitoring of patient (6 years or older) in sleep lab cpt 95810 2442.48 2442.48 792.34 792.34 4724.57 4724.57 3937.14 3937.14 O 805.22 805.22 humana medicare advantage hmo "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 97.3 97.3 humana medicare advantage hmo "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 97.3 97.3 humana medicare advantage pos "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 97.3 97.3 humana medicare advantage ppo "X-ray of sacroiliac joints, 3 or more views" cpt 72202 97.3 97.3 21.76 21.76 272.21 272.21 226.84 226.84 O 97.3 97.3 humana medicare advantage hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2102.95 2102.95 2102.95 2102.95 25974.02 25974.02 21645.02 21645.02 E 2102.95 2102.95 humana medicare advantage hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2102.95 2102.95 2102.95 2102.95 25974.02 25974.02 21645.02 21645.02 E 2102.95 2102.95 humana medicare advantage pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2102.95 2102.95 2102.95 2102.95 25974.02 25974.02 21645.02 21645.02 E 2102.95 2102.95 humana medicare advantage ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2102.95 2102.95 2102.95 2102.95 25974.02 25974.02 21645.02 21645.02 E 2102.95 2102.95 humana medicare advantage hmo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 337.39 337.39 humana medicare advantage hmo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 337.39 337.39 humana medicare advantage pos MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 337.39 337.39 humana medicare advantage ppo MRI scan of pelvis before and after contrast cpt 72197 868.48 868.48 288.37 288.37 3107.5 3107.5 2589.58 2589.58 O 337.39 337.39 humana medicare advantage hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 626.66 626.66 humana medicare advantage hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 626.66 626.66 humana medicare advantage pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 626.66 626.66 humana medicare advantage ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 626.66 626.66 humana medicare advantage hmo CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage hmo CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage pos CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage ppo CT scan pelvis cpt 72192 559.23 559.23 99.29 99.29 1367.4 1367.4 1139.5 1139.5 O 99.29 99.29 humana medicare advantage hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 humana medicare advantage hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 humana medicare advantage pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 humana medicare advantage ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 humana medicare advantage hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 99.29 99.29 humana medicare advantage hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 99.29 99.29 humana medicare advantage pos CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 99.29 99.29 humana medicare advantage ppo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 99.29 99.29 humana medicare advantage hmo MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage hmo MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage pos MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage ppo MRI scan of lower spinal canal before and after contrast cpt 72158 419.53 419.53 218.02 218.02 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage hmo MRI scan of lower spinal canal before and after contrast cpt 72158 338.27 338.27 218.02 218.02 4123.82 4123.82 3436.52 3436.52 E 338.27 338.27 humana medicare advantage hmo MRI scan of lower spinal canal before and after contrast cpt 72158 338.27 338.27 218.02 218.02 4123.82 4123.82 3436.52 3436.52 E 338.27 338.27 humana medicare advantage pos MRI scan of lower spinal canal before and after contrast cpt 72158 338.27 338.27 218.02 218.02 4123.82 4123.82 3436.52 3436.52 E 338.27 338.27 humana medicare advantage ppo MRI scan of lower spinal canal before and after contrast cpt 72158 338.27 338.27 218.02 218.02 4123.82 4123.82 3436.52 3436.52 E 338.27 338.27 humana medicare advantage hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 99.29 99.29 humana medicare advantage hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 99.29 99.29 humana medicare advantage pos CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 99.29 99.29 humana medicare advantage ppo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 99.29 99.29 humana medicare advantage hmo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage hmo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage pos MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage ppo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 338.27 338.27 humana medicare advantage hmo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage hmo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage pos "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage ppo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage hmo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 766.68 766.68 humana medicare advantage hmo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 766.68 766.68 humana medicare advantage pos MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 766.68 766.68 humana medicare advantage ppo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 766.68 766.68 humana medicare advantage hmo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 humana medicare advantage hmo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 humana medicare advantage pos MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 humana medicare advantage ppo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 humana medicare advantage hmo MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 756.35 756.35 humana medicare advantage hmo MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 756.35 756.35 humana medicare advantage pos MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 756.35 756.35 humana medicare advantage ppo MRI scan of upper spinal canal before and after contrast cpt 72156 756.35 756.35 218.62 218.62 4123.82 4123.82 3436.52 3436.52 O 756.35 756.35 humana medicare advantage hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage pos MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage ppo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage pos MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage ppo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage pos MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage ppo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 humana medicare advantage hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 humana medicare advantage pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 humana medicare advantage ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 humana medicare advantage hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 408.55 408.55 humana medicare advantage hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 408.55 408.55 humana medicare advantage pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 408.55 408.55 humana medicare advantage ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 408.55 408.55 humana medicare advantage hmo MRI scan of middle spinal canal cpt 72146 481.19 481.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 E 481.19 481.19 humana medicare advantage hmo MRI scan of middle spinal canal cpt 72146 481.19 481.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 E 481.19 481.19 humana medicare advantage pos MRI scan of middle spinal canal cpt 72146 481.19 481.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 E 481.19 481.19 humana medicare advantage ppo MRI scan of middle spinal canal cpt 72146 481.19 481.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 E 481.19 481.19 humana medicare advantage hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 99.29 99.29 humana medicare advantage hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 99.29 99.29 humana medicare advantage pos "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 99.29 99.29 humana medicare advantage ppo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 99.29 99.29 humana medicare advantage hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 99.29 99.29 humana medicare advantage hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 99.29 99.29 humana medicare advantage pos Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 99.29 99.29 humana medicare advantage ppo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 99.29 99.29 humana medicare advantage hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage pos MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 99.29 99.29 humana medicare advantage hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 99.29 99.29 humana medicare advantage pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 99.29 99.29 humana medicare advantage ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 99.29 99.29 humana medicare advantage hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 99.29 99.29 humana medicare advantage hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 99.29 99.29 humana medicare advantage pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 99.29 99.29 humana medicare advantage ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 99.29 99.29 humana medicare advantage hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 83.77 83.77 humana medicare advantage hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 83.77 83.77 humana medicare advantage pos Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 83.77 83.77 humana medicare advantage ppo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 83.77 83.77 humana medicare advantage hmo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage pos CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage ppo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 106.79 106.79 humana medicare advantage hmo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 106.79 106.79 humana medicare advantage pos Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 106.79 106.79 humana medicare advantage ppo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 106.79 106.79 humana medicare advantage hmo CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage hmo CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage pos CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage ppo CT scan of lower spine cpt 72131 876.81 876.81 90.7 90.7 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 humana medicare advantage hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 humana medicare advantage pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 humana medicare advantage ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 humana medicare advantage hmo CT scan of middle spine cpt 72128 155.14 155.14 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo CT scan of middle spine cpt 72128 155.14 155.14 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage pos CT scan of middle spine cpt 72128 155.14 155.14 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage ppo CT scan of middle spine cpt 72128 155.14 155.14 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo "limb reattachment, hip and femur procedures for multiple significant trauma" ms-drg 956 19361.18 19361.18 520.19 520.19 76918.36 76918.36 64098.63 64098.63 I 520.19 520.19 humana medicare advantage hmo "limb reattachment, hip and femur procedures for multiple significant trauma" ms-drg 956 19361.18 19361.18 520.19 520.19 76918.36 76918.36 64098.63 64098.63 I 520.19 520.19 humana medicare advantage pos "limb reattachment, hip and femur procedures for multiple significant trauma" ms-drg 956 19361.18 19361.18 520.19 520.19 76918.36 76918.36 64098.63 64098.63 I 520.19 520.19 humana medicare advantage ppo "limb reattachment, hip and femur procedures for multiple significant trauma" ms-drg 956 19361.18 19361.18 520.19 520.19 76918.36 76918.36 64098.63 64098.63 I 520.19 520.19 humana medicare advantage hmo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage pos CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage ppo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 humana medicare advantage hmo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 humana medicare advantage pos "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 humana medicare advantage ppo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 696.23 696.23 humana medicare advantage hmo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage hmo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage pos CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage ppo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 156.86 156.86 humana medicare advantage hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 2683.78 2683.78 1571.32 1571.32 16653.78 16653.78 13878.15 13878.15 E 2683.78 2683.78 humana medicare advantage hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 2683.78 2683.78 1571.32 1571.32 16653.78 16653.78 13878.15 13878.15 E 2683.78 2683.78 humana medicare advantage pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 2683.78 2683.78 1571.32 1571.32 16653.78 16653.78 13878.15 13878.15 E 2683.78 2683.78 humana medicare advantage ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 2683.78 2683.78 1571.32 1571.32 16653.78 16653.78 13878.15 13878.15 E 2683.78 2683.78 humana medicare advantage hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1034.59 1034.59 humana medicare advantage hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1034.59 1034.59 humana medicare advantage pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1034.59 1034.59 humana medicare advantage ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 1034.59 1034.59 humana medicare advantage hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2598.04 2598.04 2598.04 2598.04 16897.38 16897.38 14081.15 14081.15 E 2598.04 2598.04 humana medicare advantage hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2598.04 2598.04 2598.04 2598.04 16897.38 16897.38 14081.15 14081.15 E 2598.04 2598.04 humana medicare advantage pos Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2598.04 2598.04 2598.04 2598.04 16897.38 16897.38 14081.15 14081.15 E 2598.04 2598.04 humana medicare advantage ppo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2598.04 2598.04 2598.04 2598.04 16897.38 16897.38 14081.15 14081.15 E 2598.04 2598.04 humana medicare advantage hmo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 99.29 99.29 humana medicare advantage hmo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 99.29 99.29 humana medicare advantage pos X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 99.29 99.29 humana medicare advantage ppo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 99.29 99.29 humana medicare advantage hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 676.71 676.71 humana medicare advantage hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 676.71 676.71 humana medicare advantage pos Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 676.71 676.71 humana medicare advantage ppo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 676.71 676.71 humana medicare advantage hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1237.74 1237.74 humana medicare advantage hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1237.74 1237.74 humana medicare advantage pos Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1237.74 1237.74 humana medicare advantage ppo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1237.74 1237.74 humana medicare advantage hmo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 1334.43 1334.43 humana medicare advantage hmo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 1334.43 1334.43 humana medicare advantage pos Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 1334.43 1334.43 humana medicare advantage ppo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 1334.43 1334.43 humana medicare advantage hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 99.29 99.29 humana medicare advantage hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 99.29 99.29 humana medicare advantage pos "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 99.29 99.29 humana medicare advantage ppo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 99.29 99.29 humana medicare advantage hmo slings cpt A4565 9081.99 9081.99 4904.09 4904.09 42712.72 42712.72 35593.93 35593.93 E 8959.3 8959.3 humana medicare advantage hmo slings cpt A4565 9081.99 9081.99 4904.09 4904.09 42712.72 42712.72 35593.93 35593.93 E 8959.3 8959.3 humana medicare advantage pos slings cpt A4565 9081.99 9081.99 4904.09 4904.09 42712.72 42712.72 35593.93 35593.93 E 8959.3 8959.3 humana medicare advantage ppo slings cpt A4565 9081.99 9081.99 4904.09 4904.09 42712.72 42712.72 35593.93 35593.93 E 8959.3 8959.3 humana medicare advantage hmo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 70.7 70.7 humana medicare advantage hmo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 70.7 70.7 humana medicare advantage pos "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 70.7 70.7 humana medicare advantage ppo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 70.7 70.7 humana medicare advantage hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 humana medicare advantage hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 humana medicare advantage pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 humana medicare advantage ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 humana medicare advantage hmo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage hmo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage pos "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage ppo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 humana medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 humana medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 humana medicare advantage ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 humana medicare advantage hmo seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 5459.75 5459.75 humana medicare advantage hmo seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 5459.75 5459.75 humana medicare advantage pos seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 5459.75 5459.75 humana medicare advantage ppo seizures without mcc ms-drg 101 6886.91 6886.91 3126.2 3126.2 31623.19 31623.19 26352.66 26352.66 I 5459.75 5459.75 humana medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 humana medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 humana medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 humana medicare advantage ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 humana medicare advantage hmo "X-ray of middle spine, 2 views" cpt 72070 99.29 99.29 17.96 17.96 328.18 328.18 273.48 273.48 O 99.29 99.29 humana medicare advantage hmo "X-ray of middle spine, 2 views" cpt 72070 99.29 99.29 17.96 17.96 328.18 328.18 273.48 273.48 O 99.29 99.29 humana medicare advantage pos "X-ray of middle spine, 2 views" cpt 72070 99.29 99.29 17.96 17.96 328.18 328.18 273.48 273.48 O 99.29 99.29 humana medicare advantage ppo "X-ray of middle spine, 2 views" cpt 72070 99.29 99.29 17.96 17.96 328.18 328.18 273.48 273.48 O 99.29 99.29 humana medicare advantage hmo other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9569.15 9569.15 humana medicare advantage hmo other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9569.15 9569.15 humana medicare advantage pos other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9569.15 9569.15 humana medicare advantage ppo other multiple significant trauma with cc ms-drg 964 9633.01 9633.01 7146.66 7146.66 32160.8 32160.8 26800.67 26800.67 I 9569.15 9569.15 humana medicare advantage hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 humana medicare advantage hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 humana medicare advantage pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 humana medicare advantage ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 13.39 13.39 humana medicare advantage hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 humana medicare advantage hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 humana medicare advantage pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 humana medicare advantage ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 humana medicare advantage hmo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 99.29 99.29 humana medicare advantage hmo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 99.29 99.29 humana medicare advantage pos "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 99.29 99.29 humana medicare advantage ppo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 99.29 99.29 humana medicare advantage hmo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 8.68 8.68 humana medicare advantage hmo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 8.68 8.68 humana medicare advantage pos Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 8.68 8.68 humana medicare advantage ppo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 8.68 8.68 humana medicare advantage hmo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage hmo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage pos "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage ppo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 99.29 99.29 humana medicare advantage hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 humana medicare advantage hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 humana medicare advantage pos Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 humana medicare advantage ppo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 humana medicare advantage hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 humana medicare advantage hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 humana medicare advantage pos "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 humana medicare advantage ppo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 humana medicare advantage hmo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 70.7 70.7 humana medicare advantage hmo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 70.7 70.7 humana medicare advantage pos "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 70.7 70.7 humana medicare advantage ppo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 70.7 70.7 humana medicare advantage hmo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage hmo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage pos CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage ppo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 humana medicare advantage hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 humana medicare advantage pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 humana medicare advantage ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 humana medicare advantage hmo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 18.39 18.39 humana medicare advantage hmo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 18.39 18.39 humana medicare advantage pos "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 18.39 18.39 humana medicare advantage ppo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 18.39 18.39 humana medicare advantage hmo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 161.43 161.43 humana medicare advantage hmo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 161.43 161.43 humana medicare advantage pos CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 161.43 161.43 humana medicare advantage ppo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 161.43 161.43 humana medicare advantage hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 humana medicare advantage hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 humana medicare advantage pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 humana medicare advantage ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 humana medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 90 90 humana medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 90 90 humana medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 90 90 humana medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 90 90 humana medicare advantage hmo CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 161.43 161.43 humana medicare advantage hmo CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 161.43 161.43 humana medicare advantage pos CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 161.43 161.43 humana medicare advantage ppo CT scan chest before and after contrast cpt 71270 808.13 808.13 158.85 158.85 2753.88 2753.88 2294.9 2294.9 O 161.43 161.43 humana medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 humana medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 humana medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 humana medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 humana medicare advantage hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage pos CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 humana medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 humana medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 humana medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 humana medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 humana medicare advantage hmo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 8752.86 8752.86 humana medicare advantage hmo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 8752.86 8752.86 humana medicare advantage pos extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 8752.86 8752.86 humana medicare advantage ppo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 8752.86 8752.86 humana medicare advantage hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 humana medicare advantage hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 humana medicare advantage pos "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 humana medicare advantage ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 humana medicare advantage hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 406.78 406.78 humana medicare advantage hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 406.78 406.78 humana medicare advantage pos ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 406.78 406.78 humana medicare advantage ppo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 406.78 406.78 humana medicare advantage hmo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage pos CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage ppo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 99.29 99.29 humana medicare advantage hmo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 429.57 429.57 humana medicare advantage hmo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 429.57 429.57 humana medicare advantage pos als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 429.57 429.57 humana medicare advantage ppo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 429.57 429.57 humana medicare advantage hmo bls cpt A0428 911.16 911.16 251.75 251.75 819.6 819.6 683 683 O 572.32 572.32 humana medicare advantage hmo bls cpt A0428 911.16 911.16 251.75 251.75 819.6 819.6 683 683 O 572.32 572.32 humana medicare advantage pos bls cpt A0428 911.16 911.16 251.75 251.75 819.6 819.6 683 683 O 572.32 572.32 humana medicare advantage ppo bls cpt A0428 911.16 911.16 251.75 251.75 819.6 819.6 683 683 O 572.32 572.32 humana medicare advantage hmo bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 380.3 380.3 humana medicare advantage hmo bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 380.3 380.3 humana medicare advantage pos bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 380.3 380.3 humana medicare advantage ppo bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 380.3 380.3 humana medicare advantage hmo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 1974.1 1974.1 humana medicare advantage hmo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 1974.1 1974.1 humana medicare advantage pos slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 1974.1 1974.1 humana medicare advantage ppo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 1974.1 1974.1 humana medicare advantage hmo "X-ray of both sides of the ribs including the chest, minimum of 4 views" cpt 71111 99.29 99.29 29.33 29.33 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage hmo "X-ray of both sides of the ribs including the chest, minimum of 4 views" cpt 71111 99.29 99.29 29.33 29.33 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage pos "X-ray of both sides of the ribs including the chest, minimum of 4 views" cpt 71111 99.29 99.29 29.33 29.33 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage ppo "X-ray of both sides of the ribs including the chest, minimum of 4 views" cpt 71111 99.29 99.29 29.33 29.33 384.14 384.14 320.12 320.12 O 99.29 99.29 humana medicare advantage hmo implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 1103.22 1103.22 humana medicare advantage hmo implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 1103.22 1103.22 humana medicare advantage pos implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 1103.22 1103.22 humana medicare advantage ppo implantable tissue marker cpt A4648 8915.14 8915.14 1103.22 1103.22 32134.67 32134.67 26778.89 26778.89 O 1103.22 1103.22 humana medicare advantage hmo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 95.82 95.82 humana medicare advantage hmo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 95.82 95.82 humana medicare advantage pos "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 95.82 95.82 humana medicare advantage ppo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 95.82 95.82 humana medicare advantage hmo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 102.7 102.7 humana medicare advantage hmo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 102.7 102.7 humana medicare advantage pos alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 102.7 102.7 humana medicare advantage ppo alginate dressing <=16 sq in cpt A6196 725.19 725.19 65.7 65.7 1176.96 1176.96 980.8 980.8 O 102.7 102.7 humana medicare advantage hmo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 70.7 70.7 humana medicare advantage hmo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 70.7 70.7 humana medicare advantage pos "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 70.7 70.7 humana medicare advantage ppo "X-ray of ribs of one side of body, 2 views" cpt 71100 213.26 213.26 20.29 20.29 433.75 433.75 361.46 361.46 O 70.7 70.7 humana medicare advantage hmo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 278.29 278.29 humana medicare advantage hmo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 278.29 278.29 humana medicare advantage pos alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 278.29 278.29 humana medicare advantage ppo alginate drsg >16 <=48 sq in cpt A6197 616.41 616.41 64.43 64.43 1471.2 1471.2 1226 1226 O 278.29 278.29 humana medicare advantage hmo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 humana medicare advantage hmo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 humana medicare advantage pos absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 humana medicare advantage ppo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 humana medicare advantage hmo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 humana medicare advantage hmo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 humana medicare advantage pos tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 humana medicare advantage ppo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 humana medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.7 70.7 humana medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.7 70.7 humana medicare advantage pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.7 70.7 humana medicare advantage ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.7 70.7 humana medicare advantage hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 humana medicare advantage hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 humana medicare advantage pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 humana medicare advantage ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1127.01 1127.01 humana medicare advantage hmo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 664.39 664.39 humana medicare advantage hmo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 664.39 664.39 humana medicare advantage pos tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 664.39 664.39 humana medicare advantage ppo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 664.39 664.39 humana medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 70.7 70.7 humana medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 70.7 70.7 humana medicare advantage pos "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 70.7 70.7 humana medicare advantage ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 70.7 70.7 humana medicare advantage hmo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 415.66 415.66 humana medicare advantage hmo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 415.66 415.66 humana medicare advantage pos tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 415.66 415.66 humana medicare advantage ppo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 415.66 415.66 humana medicare advantage hmo tc99m pyrophosphate cpt A9538 326.12 326.12 320.9 320.9 2718.01 2718.01 2265.01 2265.01 O 326.12 326.12 humana medicare advantage hmo tc99m pyrophosphate cpt A9538 326.12 326.12 320.9 320.9 2718.01 2718.01 2265.01 2265.01 O 326.12 326.12 humana medicare advantage pos tc99m pyrophosphate cpt A9538 326.12 326.12 320.9 320.9 2718.01 2718.01 2265.01 2265.01 O 326.12 326.12 humana medicare advantage ppo tc99m pyrophosphate cpt A9538 326.12 326.12 320.9 320.9 2718.01 2718.01 2265.01 2265.01 O 326.12 326.12 humana medicare advantage hmo tc99m pentetate cpt A9539 421.27 421.27 260.45 260.45 1775.23 1775.23 1479.36 1479.36 O 418.12 418.12 humana medicare advantage hmo tc99m pentetate cpt A9539 421.27 421.27 260.45 260.45 1775.23 1775.23 1479.36 1479.36 O 418.12 418.12 humana medicare advantage pos tc99m pentetate cpt A9539 421.27 421.27 260.45 260.45 1775.23 1775.23 1479.36 1479.36 O 418.12 418.12 humana medicare advantage ppo tc99m pentetate cpt A9539 421.27 421.27 260.45 260.45 1775.23 1775.23 1479.36 1479.36 O 418.12 418.12 humana medicare advantage hmo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 326.12 326.12 humana medicare advantage hmo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 326.12 326.12 humana medicare advantage pos tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 326.12 326.12 humana medicare advantage ppo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 326.12 326.12 humana medicare advantage hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 humana medicare advantage hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 humana medicare advantage pos f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 humana medicare advantage ppo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 humana medicare advantage hmo "gad-base mr contrast nos,1ml" cpt A9579 1952.13 1952.13 1005.31 1005.31 14304.31 14304.31 11920.26 11920.26 E 1952.13 1952.13 humana medicare advantage hmo "gad-base mr contrast nos,1ml" cpt A9579 1952.13 1952.13 1005.31 1005.31 14304.31 14304.31 11920.26 11920.26 E 1952.13 1952.13 humana medicare advantage pos "gad-base mr contrast nos,1ml" cpt A9579 1952.13 1952.13 1005.31 1005.31 14304.31 14304.31 11920.26 11920.26 E 1952.13 1952.13 humana medicare advantage ppo "gad-base mr contrast nos,1ml" cpt A9579 1952.13 1952.13 1005.31 1005.31 14304.31 14304.31 11920.26 11920.26 E 1952.13 1952.13 humana medicare advantage hmo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 humana medicare advantage hmo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 humana medicare advantage pos "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 humana medicare advantage ppo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 70.7 70.7 humana medicare advantage hmo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 338.27 338.27 humana medicare advantage hmo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 338.27 338.27 humana medicare advantage pos "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 338.27 338.27 humana medicare advantage ppo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 338.27 338.27 humana medicare advantage hmo radium ra223 dichloride ther cpt A9606 20035.66 20035.66 20035.66 20035.66 85087.9 85087.9 70906.58 70906.58 O 20035.66 20035.66 humana medicare advantage hmo radium ra223 dichloride ther cpt A9606 20035.66 20035.66 20035.66 20035.66 85087.9 85087.9 70906.58 70906.58 O 20035.66 20035.66 humana medicare advantage pos radium ra223 dichloride ther cpt A9606 20035.66 20035.66 20035.66 20035.66 85087.9 85087.9 70906.58 70906.58 O 20035.66 20035.66 humana medicare advantage ppo radium ra223 dichloride ther cpt A9606 20035.66 20035.66 20035.66 20035.66 85087.9 85087.9 70906.58 70906.58 O 20035.66 20035.66 humana medicare advantage hmo "anchor/screw bn/bn,tis/bn" cpt C1713 8777.72 8777.72 1569.38 1569.38 43374.37 43374.37 36145.31 36145.31 E 8777.72 8777.72 humana medicare advantage hmo "anchor/screw bn/bn,tis/bn" cpt C1713 8777.72 8777.72 1569.38 1569.38 43374.37 43374.37 36145.31 36145.31 E 8777.72 8777.72 humana medicare advantage pos "anchor/screw bn/bn,tis/bn" cpt C1713 8777.72 8777.72 1569.38 1569.38 43374.37 43374.37 36145.31 36145.31 E 8777.72 8777.72 humana medicare advantage ppo "anchor/screw bn/bn,tis/bn" cpt C1713 8777.72 8777.72 1569.38 1569.38 43374.37 43374.37 36145.31 36145.31 E 8777.72 8777.72 humana medicare advantage hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 5249.25 5249.25 humana medicare advantage hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 5249.25 5249.25 humana medicare advantage pos "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 5249.25 5249.25 humana medicare advantage ppo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 5249.25 5249.25 humana medicare advantage hmo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 11449.31 11449.31 humana medicare advantage hmo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 11449.31 11449.31 humana medicare advantage pos "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 11449.31 11449.31 humana medicare advantage ppo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 11449.31 11449.31 humana medicare advantage hmo "aicd, dual chamber" cpt C1721 28598.55 28598.55 19750.59 19750.59 107408.74 107408.74 89507.28 89507.28 O 28598.55 28598.55 humana medicare advantage hmo "aicd, dual chamber" cpt C1721 28598.55 28598.55 19750.59 19750.59 107408.74 107408.74 89507.28 89507.28 O 28598.55 28598.55 humana medicare advantage pos "aicd, dual chamber" cpt C1721 28598.55 28598.55 19750.59 19750.59 107408.74 107408.74 89507.28 89507.28 O 28598.55 28598.55 humana medicare advantage ppo "aicd, dual chamber" cpt C1721 28598.55 28598.55 19750.59 19750.59 107408.74 107408.74 89507.28 89507.28 O 28598.55 28598.55 humana medicare advantage hmo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 humana medicare advantage hmo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 humana medicare advantage pos "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 humana medicare advantage ppo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 humana medicare advantage hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 70.7 70.7 humana medicare advantage hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 70.7 70.7 humana medicare advantage pos "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 70.7 70.7 humana medicare advantage ppo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 70.7 70.7 humana medicare advantage hmo "cath, translumin non-laser" cpt C1725 13873.2 13873.2 6589.84 6589.84 75620.26 75620.26 63016.88 63016.88 E 6589.84 6589.84 humana medicare advantage hmo "cath, translumin non-laser" cpt C1725 13873.2 13873.2 6589.84 6589.84 75620.26 75620.26 63016.88 63016.88 E 6589.84 6589.84 humana medicare advantage pos "cath, translumin non-laser" cpt C1725 13873.2 13873.2 6589.84 6589.84 75620.26 75620.26 63016.88 63016.88 E 6589.84 6589.84 humana medicare advantage ppo "cath, translumin non-laser" cpt C1725 13873.2 13873.2 6589.84 6589.84 75620.26 75620.26 63016.88 63016.88 E 6589.84 6589.84 humana medicare advantage hmo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 8777.72 8777.72 humana medicare advantage hmo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 8777.72 8777.72 humana medicare advantage pos "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 8777.72 8777.72 humana medicare advantage ppo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 8777.72 8777.72 humana medicare advantage hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 humana medicare advantage hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 humana medicare advantage pos "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 humana medicare advantage ppo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 humana medicare advantage hmo "cath, hemodialysis,long-term" cpt C1750 2455.02 2455.02 2415.74 2415.74 19732.02 19732.02 16443.35 16443.35 O 2455.02 2455.02 humana medicare advantage hmo "cath, hemodialysis,long-term" cpt C1750 2455.02 2455.02 2415.74 2415.74 19732.02 19732.02 16443.35 16443.35 O 2455.02 2455.02 humana medicare advantage pos "cath, hemodialysis,long-term" cpt C1750 2455.02 2455.02 2415.74 2415.74 19732.02 19732.02 16443.35 16443.35 O 2455.02 2455.02 humana medicare advantage ppo "cath, hemodialysis,long-term" cpt C1750 2455.02 2455.02 2415.74 2415.74 19732.02 19732.02 16443.35 16443.35 O 2455.02 2455.02 humana medicare advantage hmo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 humana medicare advantage hmo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 humana medicare advantage pos "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 humana medicare advantage ppo "cath, inf, per/cent/midline" cpt C1751 14345.81 14345.81 2405.95 2405.95 20727.73 20727.73 17273.11 17273.11 O 2524.71 2524.71 humana medicare advantage hmo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage pos MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage ppo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 206.45 206.45 humana medicare advantage hmo "cath, intravas ultrasound" cpt C1753 14120.9 14120.9 8777.72 8777.72 81705.65 81705.65 68088.04 68088.04 O 14120.9 14120.9 humana medicare advantage hmo "cath, intravas ultrasound" cpt C1753 14120.9 14120.9 8777.72 8777.72 81705.65 81705.65 68088.04 68088.04 O 14120.9 14120.9 humana medicare advantage pos "cath, intravas ultrasound" cpt C1753 14120.9 14120.9 8777.72 8777.72 81705.65 81705.65 68088.04 68088.04 O 14120.9 14120.9 humana medicare advantage ppo "cath, intravas ultrasound" cpt C1753 14120.9 14120.9 8777.72 8777.72 81705.65 81705.65 68088.04 68088.04 O 14120.9 14120.9 humana medicare advantage hmo "cath, pacing, transesoph" cpt C1756 6636.16 6636.16 6636.16 6636.16 71969.58 71969.58 59974.65 59974.65 O 6636.16 6636.16 humana medicare advantage hmo "cath, pacing, transesoph" cpt C1756 6636.16 6636.16 6636.16 6636.16 71969.58 71969.58 59974.65 59974.65 O 6636.16 6636.16 humana medicare advantage pos "cath, pacing, transesoph" cpt C1756 6636.16 6636.16 6636.16 6636.16 71969.58 71969.58 59974.65 59974.65 O 6636.16 6636.16 humana medicare advantage ppo "cath, pacing, transesoph" cpt C1756 6636.16 6636.16 6636.16 6636.16 71969.58 71969.58 59974.65 59974.65 O 6636.16 6636.16 humana medicare advantage hmo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 3676.69 3676.69 humana medicare advantage hmo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 3676.69 3676.69 humana medicare advantage pos "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 3676.69 3676.69 humana medicare advantage ppo "catheter, ureteral" cpt C1758 4681.97 4681.97 1541.69 1541.69 22733.84 22733.84 18944.87 18944.87 O 3676.69 3676.69 humana medicare advantage hmo "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 8777.72 8777.72 humana medicare advantage hmo "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 8777.72 8777.72 humana medicare advantage pos "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 8777.72 8777.72 humana medicare advantage ppo "closure dev, vasc" cpt C1760 8777.72 8777.72 706.25 706.25 78433.24 78433.24 65361.03 65361.03 O 8777.72 8777.72 humana medicare advantage hmo guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 4401.96 4401.96 humana medicare advantage hmo guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 4401.96 4401.96 humana medicare advantage pos guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 4401.96 4401.96 humana medicare advantage ppo guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 4401.96 4401.96 humana medicare advantage hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 4388.57 4388.57 humana medicare advantage hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 4388.57 4388.57 humana medicare advantage pos guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 4388.57 4388.57 humana medicare advantage ppo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 4388.57 4388.57 humana medicare advantage hmo "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 338.27 338.27 humana medicare advantage hmo "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 338.27 338.27 humana medicare advantage pos "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 338.27 338.27 humana medicare advantage ppo "MRI scan bones of the eye, face, and/or neck before and after contrast" cpt 70543 481.31 481.31 287.84 287.84 2275.61 2275.61 1896.34 1896.34 O 338.27 338.27 humana medicare advantage hmo CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage hmo CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage pos CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage ppo CT scan of neck blood vessels with contrast cpt 70498 465.78 465.78 158.85 158.85 1985.59 1985.59 1654.66 1654.66 O 161.43 161.43 humana medicare advantage hmo "lead, aicd, endo single coil" cpt C1777 28598.55 28598.55 26166.91 26166.91 118891.24 118891.24 99076.03 99076.03 O 28598.55 28598.55 humana medicare advantage hmo "lead, aicd, endo single coil" cpt C1777 28598.55 28598.55 26166.91 26166.91 118891.24 118891.24 99076.03 99076.03 O 28598.55 28598.55 humana medicare advantage pos "lead, aicd, endo single coil" cpt C1777 28598.55 28598.55 26166.91 26166.91 118891.24 118891.24 99076.03 99076.03 O 28598.55 28598.55 humana medicare advantage ppo "lead, aicd, endo single coil" cpt C1777 28598.55 28598.55 26166.91 26166.91 118891.24 118891.24 99076.03 99076.03 O 28598.55 28598.55 humana medicare advantage hmo CT scan of neck blood vessels with contrast cpt 70498 408.55 408.55 168.41 168.41 1985.59 1985.59 1654.66 1654.66 E 408.55 408.55 humana medicare advantage hmo CT scan of neck blood vessels with contrast cpt 70498 408.55 408.55 168.41 168.41 1985.59 1985.59 1654.66 1654.66 E 408.55 408.55 humana medicare advantage pos CT scan of neck blood vessels with contrast cpt 70498 408.55 408.55 168.41 168.41 1985.59 1985.59 1654.66 1654.66 E 408.55 408.55 humana medicare advantage ppo CT scan of neck blood vessels with contrast cpt 70498 408.55 408.55 168.41 168.41 1985.59 1985.59 1654.66 1654.66 E 408.55 408.55 humana medicare advantage hmo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 4282.09 4282.09 humana medicare advantage hmo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 4282.09 4282.09 humana medicare advantage pos mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 4282.09 4282.09 humana medicare advantage ppo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 4282.09 4282.09 humana medicare advantage hmo "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage pos "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage ppo "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 9007.23 9007.23 40080.85 40080.85 33400.71 33400.71 O 9081.99 9081.99 humana medicare advantage hmo "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 9007.23 9007.23 40080.85 40080.85 33400.71 33400.71 O 9081.99 9081.99 humana medicare advantage pos "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 9007.23 9007.23 40080.85 40080.85 33400.71 33400.71 O 9081.99 9081.99 humana medicare advantage ppo "pmkr, dual, rate-resp" cpt C1785 9081.99 9081.99 9007.23 9007.23 40080.85 40080.85 33400.71 33400.71 O 9081.99 9081.99 humana medicare advantage hmo "pmkr, single, rate-resp" cpt C1786 8928.51 8928.51 6769.76 6769.76 33957.7 33957.7 28298.08 28298.08 O 6769.76 6769.76 humana medicare advantage hmo "pmkr, single, rate-resp" cpt C1786 8928.51 8928.51 6769.76 6769.76 33957.7 33957.7 28298.08 28298.08 O 6769.76 6769.76 humana medicare advantage pos "pmkr, single, rate-resp" cpt C1786 8928.51 8928.51 6769.76 6769.76 33957.7 33957.7 28298.08 28298.08 O 6769.76 6769.76 humana medicare advantage ppo "pmkr, single, rate-resp" cpt C1786 8928.51 8928.51 6769.76 6769.76 33957.7 33957.7 28298.08 28298.08 O 6769.76 6769.76 humana medicare advantage hmo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2418.19 2418.19 humana medicare advantage hmo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2418.19 2418.19 humana medicare advantage pos "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2418.19 2418.19 humana medicare advantage ppo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2418.19 2418.19 humana medicare advantage hmo "stent, coated/cov w/del sys" cpt C1874 13873.2 13873.2 8777.72 8777.72 83814.13 83814.13 69845.11 69845.11 E 8777.72 8777.72 humana medicare advantage hmo "stent, coated/cov w/del sys" cpt C1874 13873.2 13873.2 8777.72 8777.72 83814.13 83814.13 69845.11 69845.11 E 8777.72 8777.72 humana medicare advantage pos "stent, coated/cov w/del sys" cpt C1874 13873.2 13873.2 8777.72 8777.72 83814.13 83814.13 69845.11 69845.11 E 8777.72 8777.72 humana medicare advantage ppo "stent, coated/cov w/del sys" cpt C1874 13873.2 13873.2 8777.72 8777.72 83814.13 83814.13 69845.11 69845.11 E 8777.72 8777.72 humana medicare advantage hmo "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 8777.72 8777.72 humana medicare advantage hmo "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 8777.72 8777.72 humana medicare advantage pos "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 8777.72 8777.72 humana medicare advantage ppo "stent, coated/cov w/del sys" cpt C1874 14156.17 14156.17 7176.4 7176.4 75662.39 75662.39 63051.99 63051.99 O 8777.72 8777.72 humana medicare advantage hmo "stent, non-coa/non-cov w/del" cpt C1876 8777.72 8777.72 3748.71 3748.71 57546.59 57546.59 47955.49 47955.49 E 8777.72 8777.72 humana medicare advantage hmo "stent, non-coa/non-cov w/del" cpt C1876 8777.72 8777.72 3748.71 3748.71 57546.59 57546.59 47955.49 47955.49 E 8777.72 8777.72 humana medicare advantage pos "stent, non-coa/non-cov w/del" cpt C1876 8777.72 8777.72 3748.71 3748.71 57546.59 57546.59 47955.49 47955.49 E 8777.72 8777.72 humana medicare advantage ppo "stent, non-coa/non-cov w/del" cpt C1876 8777.72 8777.72 3748.71 3748.71 57546.59 57546.59 47955.49 47955.49 E 8777.72 8777.72 humana medicare advantage hmo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 161.43 161.43 humana medicare advantage hmo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 161.43 161.43 humana medicare advantage pos CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 161.43 161.43 humana medicare advantage ppo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 161.43 161.43 humana medicare advantage hmo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 3748.71 3748.71 humana medicare advantage hmo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 3748.71 3748.71 humana medicare advantage pos "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 3748.71 3748.71 humana medicare advantage ppo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 3748.71 3748.71 humana medicare advantage hmo embolization protect syst cpt C1884 11328.88 11328.88 6589.84 6589.84 72908.51 72908.51 60757.09 60757.09 E 6589.84 6589.84 humana medicare advantage hmo embolization protect syst cpt C1884 11328.88 11328.88 6589.84 6589.84 72908.51 72908.51 60757.09 60757.09 E 6589.84 6589.84 humana medicare advantage pos embolization protect syst cpt C1884 11328.88 11328.88 6589.84 6589.84 72908.51 72908.51 60757.09 60757.09 E 6589.84 6589.84 humana medicare advantage ppo embolization protect syst cpt C1884 11328.88 11328.88 6589.84 6589.84 72908.51 72908.51 60757.09 60757.09 E 6589.84 6589.84 humana medicare advantage hmo CT scan of neck with contrast cpt 70491 161.43 161.43 112.47 112.47 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage hmo CT scan of neck with contrast cpt 70491 161.43 161.43 112.47 112.47 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage pos CT scan of neck with contrast cpt 70491 161.43 161.43 112.47 112.47 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage ppo CT scan of neck with contrast cpt 70491 161.43 161.43 112.47 112.47 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage hmo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8777.72 8777.72 humana medicare advantage hmo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8777.72 8777.72 humana medicare advantage pos embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8777.72 8777.72 humana medicare advantage ppo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 8777.72 8777.72 humana medicare advantage hmo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 humana medicare advantage hmo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 humana medicare advantage pos CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 humana medicare advantage ppo CT scan of neck cpt 70490 214.42 214.42 84.5 84.5 1366.13 1366.13 1138.44 1138.44 O 214.42 214.42 humana medicare advantage hmo "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 4401.96 4401.96 humana medicare advantage hmo "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 4401.96 4401.96 humana medicare advantage pos "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 4401.96 4401.96 humana medicare advantage ppo "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 4401.96 4401.96 humana medicare advantage hmo CT scan of face with contrast cpt 70487 161.43 161.43 93.52 93.52 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage hmo CT scan of face with contrast cpt 70487 161.43 161.43 93.52 93.52 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage pos CT scan of face with contrast cpt 70487 161.43 161.43 93.52 93.52 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage ppo CT scan of face with contrast cpt 70487 161.43 161.43 93.52 93.52 1507.32 1507.32 1256.1 1256.1 E 161.43 161.43 humana medicare advantage hmo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 8777.72 8777.72 humana medicare advantage hmo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 8777.72 8777.72 humana medicare advantage pos "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 8777.72 8777.72 humana medicare advantage ppo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 8777.72 8777.72 humana medicare advantage hmo "intro/sheath,fixed,peel-away" cpt C1892 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo "intro/sheath,fixed,peel-away" cpt C1892 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage pos "intro/sheath,fixed,peel-away" cpt C1892 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage ppo "intro/sheath,fixed,peel-away" cpt C1892 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 18840.27 18840.27 humana medicare advantage hmo "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 18840.27 18840.27 humana medicare advantage pos "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 18840.27 18840.27 humana medicare advantage ppo "intro/sheath,fixed,peel-away" cpt C1892 18840.27 18840.27 2410.83 2410.83 40076.36 40076.36 33396.97 33396.97 O 18840.27 18840.27 humana medicare advantage hmo "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 8777.72 8777.72 humana medicare advantage hmo "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 8777.72 8777.72 humana medicare advantage pos "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 8777.72 8777.72 humana medicare advantage ppo "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 8777.72 8777.72 humana medicare advantage hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 4202.35 4202.35 humana medicare advantage hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 4202.35 4202.35 humana medicare advantage pos "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 4202.35 4202.35 humana medicare advantage ppo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 4202.35 4202.35 humana medicare advantage hmo "lead, pmkr, other than trans" cpt C1898 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo "lead, pmkr, other than trans" cpt C1898 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage pos "lead, pmkr, other than trans" cpt C1898 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage ppo "lead, pmkr, other than trans" cpt C1898 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo "lead, pmkr, other than trans" cpt C1898 26166.91 26166.91 9081.99 9081.99 40405.91 40405.91 33671.59 33671.59 O 18840.27 18840.27 humana medicare advantage hmo "lead, pmkr, other than trans" cpt C1898 26166.91 26166.91 9081.99 9081.99 40405.91 40405.91 33671.59 33671.59 O 18840.27 18840.27 humana medicare advantage pos "lead, pmkr, other than trans" cpt C1898 26166.91 26166.91 9081.99 9081.99 40405.91 40405.91 33671.59 33671.59 O 18840.27 18840.27 humana medicare advantage ppo "lead, pmkr, other than trans" cpt C1898 26166.91 26166.91 9081.99 9081.99 40405.91 40405.91 33671.59 33671.59 O 18840.27 18840.27 humana medicare advantage hmo "stent, non-cor, tem w/o del" cpt C2617 3748.71 3748.71 2631.27 2631.27 31516.26 31516.26 26263.55 26263.55 E 3748.71 3748.71 humana medicare advantage hmo "stent, non-cor, tem w/o del" cpt C2617 3748.71 3748.71 2631.27 2631.27 31516.26 31516.26 26263.55 26263.55 E 3748.71 3748.71 humana medicare advantage pos "stent, non-cor, tem w/o del" cpt C2617 3748.71 3748.71 2631.27 2631.27 31516.26 31516.26 26263.55 26263.55 E 3748.71 3748.71 humana medicare advantage ppo "stent, non-cor, tem w/o del" cpt C2617 3748.71 3748.71 2631.27 2631.27 31516.26 31516.26 26263.55 26263.55 E 3748.71 3748.71 humana medicare advantage hmo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage hmo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage pos CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage ppo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage hmo "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 2674.06 2674.06 humana medicare advantage hmo "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 2674.06 2674.06 humana medicare advantage pos "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 2674.06 2674.06 humana medicare advantage ppo "stent, non-cor, tem w/o del" cpt C2617 8848.19 8848.19 2456.25 2456.25 22769.68 22769.68 18974.73 18974.73 O 2674.06 2674.06 humana medicare advantage hmo "cath, translumin, drug-coat" cpt C2623 11375.62 11375.62 4318.35 4318.35 105399.55 105399.55 87832.96 87832.96 O 8646.05 8646.05 humana medicare advantage hmo "cath, translumin, drug-coat" cpt C2623 11375.62 11375.62 4318.35 4318.35 105399.55 105399.55 87832.96 87832.96 O 8646.05 8646.05 humana medicare advantage pos "cath, translumin, drug-coat" cpt C2623 11375.62 11375.62 4318.35 4318.35 105399.55 105399.55 87832.96 87832.96 O 8646.05 8646.05 humana medicare advantage ppo "cath, translumin, drug-coat" cpt C2623 11375.62 11375.62 4318.35 4318.35 105399.55 105399.55 87832.96 87832.96 O 8646.05 8646.05 humana medicare advantage hmo "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 3679.64 3679.64 humana medicare advantage hmo "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 3679.64 3679.64 humana medicare advantage pos "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 3679.64 3679.64 humana medicare advantage ppo "intro/sheath, laser" cpt C2629 4436.99 4436.99 2985.59 2985.59 26294.69 26294.69 21912.24 21912.24 O 3679.64 3679.64 humana medicare advantage hmo perc drug-el cor stent sing cpt C9600 11328.88 11328.88 8777.72 8777.72 81384.32 81384.32 67820.27 67820.27 E 8777.72 8777.72 humana medicare advantage hmo perc drug-el cor stent sing cpt C9600 11328.88 11328.88 8777.72 8777.72 81384.32 81384.32 67820.27 67820.27 E 8777.72 8777.72 humana medicare advantage pos perc drug-el cor stent sing cpt C9600 11328.88 11328.88 8777.72 8777.72 81384.32 81384.32 67820.27 67820.27 E 8777.72 8777.72 humana medicare advantage ppo perc drug-el cor stent sing cpt C9600 11328.88 11328.88 8777.72 8777.72 81384.32 81384.32 67820.27 67820.27 E 8777.72 8777.72 humana medicare advantage hmo perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 8777.72 8777.72 humana medicare advantage hmo perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 8777.72 8777.72 humana medicare advantage pos perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 8777.72 8777.72 humana medicare advantage ppo perc drug-el cor stent sing cpt C9600 14191.44 14191.44 4401.38 4401.38 76664.45 76664.45 63887.04 63887.04 O 8777.72 8777.72 humana medicare advantage hmo "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 99.29 99.29 humana medicare advantage hmo "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 99.29 99.29 humana medicare advantage pos "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 99.29 99.29 humana medicare advantage ppo "X-ray of mandible, minimum of 4 views" cpt 70110 99.29 99.29 70.78 70.78 443.93 443.93 369.94 369.94 O 99.29 99.29 humana medicare advantage hmo perc drug-el cor stent bran cpt C9601 8777.72 8777.72 8643.45 8643.45 92532.48 92532.48 77110.4 77110.4 E 8777.72 8777.72 humana medicare advantage hmo perc drug-el cor stent bran cpt C9601 8777.72 8777.72 8643.45 8643.45 92532.48 92532.48 77110.4 77110.4 E 8777.72 8777.72 humana medicare advantage pos perc drug-el cor stent bran cpt C9601 8777.72 8777.72 8643.45 8643.45 92532.48 92532.48 77110.4 77110.4 E 8777.72 8777.72 humana medicare advantage ppo perc drug-el cor stent bran cpt C9601 8777.72 8777.72 8643.45 8643.45 92532.48 92532.48 77110.4 77110.4 E 8777.72 8777.72 humana medicare advantage hmo Removal of implanted eardrum tube under anesthesia cpt 69424 4492.07 4492.07 2320.38 2320.38 12184.91 12184.91 10154.09 10154.09 O 2320.38 2320.38 humana medicare advantage hmo Removal of implanted eardrum tube under anesthesia cpt 69424 4492.07 4492.07 2320.38 2320.38 12184.91 12184.91 10154.09 10154.09 O 2320.38 2320.38 humana medicare advantage pos Removal of implanted eardrum tube under anesthesia cpt 69424 4492.07 4492.07 2320.38 2320.38 12184.91 12184.91 10154.09 10154.09 O 2320.38 2320.38 humana medicare advantage ppo Removal of implanted eardrum tube under anesthesia cpt 69424 4492.07 4492.07 2320.38 2320.38 12184.91 12184.91 10154.09 10154.09 O 2320.38 2320.38 humana medicare advantage hmo perc d-e cor revasc t cabg s cpt C9604 8777.72 8777.72 8777.72 8777.72 62252.08 62252.08 51876.73 51876.73 O 8777.72 8777.72 humana medicare advantage hmo perc d-e cor revasc t cabg s cpt C9604 8777.72 8777.72 8777.72 8777.72 62252.08 62252.08 51876.73 51876.73 O 8777.72 8777.72 humana medicare advantage pos perc d-e cor revasc t cabg s cpt C9604 8777.72 8777.72 8777.72 8777.72 62252.08 62252.08 51876.73 51876.73 O 8777.72 8777.72 humana medicare advantage ppo perc d-e cor revasc t cabg s cpt C9604 8777.72 8777.72 8777.72 8777.72 62252.08 62252.08 51876.73 51876.73 O 8777.72 8777.72 humana medicare advantage hmo perc d-e cor revasc chro sin cpt C9607 14120.9 14120.9 13866.64 13866.64 83863.39 83863.39 69886.16 69886.16 O 14120.9 14120.9 humana medicare advantage hmo perc d-e cor revasc chro sin cpt C9607 14120.9 14120.9 13866.64 13866.64 83863.39 83863.39 69886.16 69886.16 O 14120.9 14120.9 humana medicare advantage pos perc d-e cor revasc chro sin cpt C9607 14120.9 14120.9 13866.64 13866.64 83863.39 83863.39 69886.16 69886.16 O 14120.9 14120.9 humana medicare advantage ppo perc d-e cor revasc chro sin cpt C9607 14120.9 14120.9 13866.64 13866.64 83863.39 83863.39 69886.16 69886.16 O 14120.9 14120.9 humana medicare advantage hmo admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 2173.49 2173.49 humana medicare advantage hmo admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 2173.49 2173.49 humana medicare advantage pos admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 2173.49 2173.49 humana medicare advantage ppo admin influenza virus vac cpt G0008 2173.49 2173.49 617.1 617.1 15661.25 15661.25 13051.04 13051.04 E 2173.49 2173.49 humana medicare advantage hmo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 325.88 325.88 humana medicare advantage hmo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 325.88 325.88 humana medicare advantage pos admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 325.88 325.88 humana medicare advantage ppo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 325.88 325.88 humana medicare advantage hmo "Partial removal of eye fluid between the lens and retina, subtotal removal with mechanical vitrectomy" cpt 67010 1791.13 1791.13 1791.13 1791.13 32535.89 32535.89 27113.24 27113.24 O 1791.13 1791.13 humana medicare advantage hmo "Partial removal of eye fluid between the lens and retina, subtotal removal with mechanical vitrectomy" cpt 67010 1791.13 1791.13 1791.13 1791.13 32535.89 32535.89 27113.24 27113.24 O 1791.13 1791.13 humana medicare advantage pos "Partial removal of eye fluid between the lens and retina, subtotal removal with mechanical vitrectomy" cpt 67010 1791.13 1791.13 1791.13 1791.13 32535.89 32535.89 27113.24 27113.24 O 1791.13 1791.13 humana medicare advantage ppo "Partial removal of eye fluid between the lens and retina, subtotal removal with mechanical vitrectomy" cpt 67010 1791.13 1791.13 1791.13 1791.13 32535.89 32535.89 27113.24 27113.24 O 1791.13 1791.13 humana medicare advantage hmo admin pneumococcal vaccine cpt G0009 601.12 601.12 94.36 94.36 488.4 488.4 407 407 O 601.12 601.12 humana medicare advantage hmo admin pneumococcal vaccine cpt G0009 601.12 601.12 94.36 94.36 488.4 488.4 407 407 O 601.12 601.12 humana medicare advantage pos admin pneumococcal vaccine cpt G0009 601.12 601.12 94.36 94.36 488.4 488.4 407 407 O 601.12 601.12 humana medicare advantage ppo admin pneumococcal vaccine cpt G0009 601.12 601.12 94.36 94.36 488.4 488.4 407 407 O 601.12 601.12 humana medicare advantage hmo "Removal of cataract with insertion of lens, complex" cpt 66982 3382.58 3382.58 1639 1639 16101.53 16101.53 13417.94 13417.94 O 1791.13 1791.13 humana medicare advantage hmo "Removal of cataract with insertion of lens, complex" cpt 66982 3382.58 3382.58 1639 1639 16101.53 16101.53 13417.94 13417.94 O 1791.13 1791.13 humana medicare advantage pos "Removal of cataract with insertion of lens, complex" cpt 66982 3382.58 3382.58 1639 1639 16101.53 16101.53 13417.94 13417.94 O 1791.13 1791.13 humana medicare advantage ppo "Removal of cataract with insertion of lens, complex" cpt 66982 3382.58 3382.58 1639 1639 16101.53 16101.53 13417.94 13417.94 O 1791.13 1791.13 humana medicare advantage hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 66.53 66.53 humana medicare advantage hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 66.53 66.53 humana medicare advantage pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 66.53 66.53 humana medicare advantage ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 66.53 66.53 humana medicare advantage hmo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 676.71 676.71 humana medicare advantage hmo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 676.71 676.71 humana medicare advantage pos colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 676.71 676.71 humana medicare advantage ppo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 676.71 676.71 humana medicare advantage hmo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 676.71 676.71 humana medicare advantage hmo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 676.71 676.71 humana medicare advantage pos colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 676.71 676.71 humana medicare advantage ppo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 676.71 676.71 humana medicare advantage hmo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 1523.14 1523.14 humana medicare advantage hmo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 1523.14 1523.14 humana medicare advantage pos Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 1523.14 1523.14 humana medicare advantage ppo Release and/or relocation of median nerve of hand cpt 64721 8300.35 8300.35 1419 1419 15750.1 15750.1 13125.08 13125.08 O 1523.14 1523.14 humana medicare advantage hmo inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 553.72 553.72 humana medicare advantage hmo inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 553.72 553.72 humana medicare advantage pos inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 553.72 553.72 humana medicare advantage ppo inj for sacroiliac jt anesth cpt G0260 1055.98 1055.98 505.78 505.78 2273.46 2273.46 1894.55 1894.55 O 553.72 553.72 humana medicare advantage hmo occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 8777.72 8777.72 humana medicare advantage hmo occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 8777.72 8777.72 humana medicare advantage pos occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 8777.72 8777.72 humana medicare advantage ppo occlusive device in vein art cpt G0269 11308.3 11308.3 706.25 706.25 78373.13 78373.13 65310.94 65310.94 O 8777.72 8777.72 humana medicare advantage hmo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 1523.14 1523.14 humana medicare advantage hmo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 1523.14 1523.14 humana medicare advantage pos Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 1523.14 1523.14 humana medicare advantage ppo Release and/or relocation of ulnar nerve at elbow cpt 64718 9882.2 9882.2 1399 1399 16931.99 16931.99 14109.99 14109.99 O 1523.14 1523.14 humana medicare advantage hmo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 176.85 176.85 humana medicare advantage hmo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 176.85 176.85 humana medicare advantage pos "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 176.85 176.85 humana medicare advantage ppo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 176.85 176.85 humana medicare advantage hmo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 719.38 719.38 humana medicare advantage hmo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 719.38 719.38 humana medicare advantage pos "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 719.38 719.38 humana medicare advantage ppo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 719.38 719.38 humana medicare advantage hmo elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 872.07 872.07 humana medicare advantage hmo elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 872.07 872.07 humana medicare advantage pos elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 872.07 872.07 humana medicare advantage ppo elec stim other than wound cpt G0283 1387.03 1387.03 314.31 314.31 5001.5 5001.5 4167.92 4167.92 O 872.07 872.07 humana medicare advantage hmo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70.7 70.7 humana medicare advantage hmo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70.7 70.7 humana medicare advantage pos ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70.7 70.7 humana medicare advantage ppo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 70.7 70.7 humana medicare advantage hmo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 719.38 719.38 humana medicare advantage hmo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 719.38 719.38 humana medicare advantage pos "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 719.38 719.38 humana medicare advantage ppo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 719.38 719.38 humana medicare advantage hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1952.13 1952.13 humana medicare advantage hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1952.13 1952.13 humana medicare advantage pos hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1952.13 1952.13 humana medicare advantage ppo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 1952.13 1952.13 humana medicare advantage hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6263.22 6263.22 humana medicare advantage hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6263.22 6263.22 humana medicare advantage pos hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6263.22 6263.22 humana medicare advantage ppo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6263.22 6263.22 humana medicare advantage hmo "prostate biopsy, any mthd" cpt G0416 3688.73 3688.73 696.23 696.23 5130.25 5130.25 4275.21 4275.21 O 3680.94 3680.94 humana medicare advantage hmo "prostate biopsy, any mthd" cpt G0416 3688.73 3688.73 696.23 696.23 5130.25 5130.25 4275.21 4275.21 O 3680.94 3680.94 humana medicare advantage pos "prostate biopsy, any mthd" cpt G0416 3688.73 3688.73 696.23 696.23 5130.25 5130.25 4275.21 4275.21 O 3680.94 3680.94 humana medicare advantage ppo "prostate biopsy, any mthd" cpt G0416 3688.73 3688.73 696.23 696.23 5130.25 5130.25 4275.21 4275.21 O 3680.94 3680.94 humana medicare advantage hmo hospital outpt clinic visit cpt G0463 2553.53 2553.53 1934.02 1934.02 23345.64 23345.64 19454.7 19454.7 E 2553.53 2553.53 humana medicare advantage hmo hospital outpt clinic visit cpt G0463 2553.53 2553.53 1934.02 1934.02 23345.64 23345.64 19454.7 19454.7 E 2553.53 2553.53 humana medicare advantage pos hospital outpt clinic visit cpt G0463 2553.53 2553.53 1934.02 1934.02 23345.64 23345.64 19454.7 19454.7 E 2553.53 2553.53 humana medicare advantage ppo hospital outpt clinic visit cpt G0463 2553.53 2553.53 1934.02 1934.02 23345.64 23345.64 19454.7 19454.7 E 2553.53 2553.53 humana medicare advantage hmo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 719.38 719.38 humana medicare advantage hmo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 719.38 719.38 humana medicare advantage pos "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 719.38 719.38 humana medicare advantage ppo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 719.38 719.38 humana medicare advantage hmo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 humana medicare advantage hmo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 humana medicare advantage pos hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 humana medicare advantage ppo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 102.7 102.7 humana medicare advantage hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 1079.07 1079.07 humana medicare advantage hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 1079.07 1079.07 humana medicare advantage pos "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 1079.07 1079.07 humana medicare advantage ppo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 1079.07 1079.07 humana medicare advantage hmo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 788.92 788.92 humana medicare advantage hmo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 788.92 788.92 humana medicare advantage pos mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 788.92 788.92 humana medicare advantage ppo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 788.92 788.92 humana medicare advantage hmo Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 2425.05 2425.05 humana medicare advantage hmo Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 2425.05 2425.05 humana medicare advantage pos Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 2425.05 2425.05 humana medicare advantage ppo Injection of anesthetic agent and/or steroid into brachial nerve bundle of arm cpt 64415 12067.91 12067.91 2425.05 2425.05 31973.23 31973.23 26644.36 26644.36 O 2425.05 2425.05 humana medicare advantage hmo "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 5299.29 5299.29 humana medicare advantage hmo "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 5299.29 5299.29 humana medicare advantage pos "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 5299.29 5299.29 humana medicare advantage ppo "Partial removal of middle spine bone with release of spinal cord and/or nerves, lower back (lumbar) area" cpt 63047 10903.98 10903.98 5299.29 5299.29 28469 28469 23724.17 23724.17 O 5299.29 5299.29 humana medicare advantage hmo "Re-exploration of spine repair with release of lower spinal cord or nerves, single interspace" cpt 63042 10573.89 10573.89 5299.29 5299.29 30661.06 30661.06 25550.88 25550.88 O 10573.89 10573.89 humana medicare advantage hmo "Re-exploration of spine repair with release of lower spinal cord or nerves, single interspace" cpt 63042 10573.89 10573.89 5299.29 5299.29 30661.06 30661.06 25550.88 25550.88 O 10573.89 10573.89 humana medicare advantage pos "Re-exploration of spine repair with release of lower spinal cord or nerves, single interspace" cpt 63042 10573.89 10573.89 5299.29 5299.29 30661.06 30661.06 25550.88 25550.88 O 10573.89 10573.89 humana medicare advantage ppo "Re-exploration of spine repair with release of lower spinal cord or nerves, single interspace" cpt 63042 10573.89 10573.89 5299.29 5299.29 30661.06 30661.06 25550.88 25550.88 O 10573.89 10573.89 humana medicare advantage hmo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 553.72 553.72 humana medicare advantage hmo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 553.72 553.72 humana medicare advantage pos Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 553.72 553.72 humana medicare advantage ppo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 553.72 553.72 humana medicare advantage hmo azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1913.09 1913.09 humana medicare advantage hmo azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1913.09 1913.09 humana medicare advantage pos azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1913.09 1913.09 humana medicare advantage ppo azithromycin cpt J0456 1995.04 1995.04 1115 1115 13115.71 13115.71 10929.76 10929.76 E 1913.09 1913.09 humana medicare advantage hmo Injection of substance into spinal canal of upper or middle back cpt 62320 553.72 553.72 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 553.72 553.72 humana medicare advantage hmo Injection of substance into spinal canal of upper or middle back cpt 62320 553.72 553.72 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 553.72 553.72 humana medicare advantage pos Injection of substance into spinal canal of upper or middle back cpt 62320 553.72 553.72 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 553.72 553.72 humana medicare advantage ppo Injection of substance into spinal canal of upper or middle back cpt 62320 553.72 553.72 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 553.72 553.72 humana medicare advantage hmo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 928.87 928.87 humana medicare advantage hmo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 928.87 928.87 humana medicare advantage pos leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 928.87 928.87 humana medicare advantage ppo leucovorin calcium injection cpt J0640 6054.77 6054.77 928.87 928.87 19517.57 19517.57 16264.64 16264.64 O 928.87 928.87 humana medicare advantage hmo Total removal of thyroid lobe on one side of the neck cpt 60220 4282.09 4282.09 4282.09 4282.09 22389.71 22389.71 18658.09 18658.09 O 4282.09 4282.09 humana medicare advantage hmo Total removal of thyroid lobe on one side of the neck cpt 60220 4282.09 4282.09 4282.09 4282.09 22389.71 22389.71 18658.09 18658.09 O 4282.09 4282.09 humana medicare advantage pos Total removal of thyroid lobe on one side of the neck cpt 60220 4282.09 4282.09 4282.09 4282.09 22389.71 22389.71 18658.09 18658.09 O 4282.09 4282.09 humana medicare advantage ppo Total removal of thyroid lobe on one side of the neck cpt 60220 4282.09 4282.09 4282.09 4282.09 22389.71 22389.71 18658.09 18658.09 O 4282.09 4282.09 humana medicare advantage hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 275.46 275.46 humana medicare advantage hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 275.46 275.46 humana medicare advantage pos Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 275.46 275.46 humana medicare advantage ppo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 275.46 275.46 humana medicare advantage hmo "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 216.73 216.73 humana medicare advantage hmo "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 216.73 216.73 humana medicare advantage pos "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 216.73 216.73 humana medicare advantage ppo "darbepoetin alfa, non-esrd" cpt J0881 868.67 868.67 216.73 216.73 1457.28 1457.28 1214.4 1214.4 O 216.73 216.73 humana medicare advantage hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1664.34 1664.34 humana medicare advantage hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1664.34 1664.34 humana medicare advantage pos denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1664.34 1664.34 humana medicare advantage ppo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1664.34 1664.34 humana medicare advantage hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 5412.23 5412.23 humana medicare advantage hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 5412.23 5412.23 humana medicare advantage pos dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 5412.23 5412.23 humana medicare advantage ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 5412.23 5412.23 humana medicare advantage hmo Insertion of radiation therapy devices in prostate gland for radiation therapy guidance cpt 55876 1103.22 1103.22 1103.22 1103.22 41954.78 41954.78 34962.32 34962.32 O 1103.22 1103.22 humana medicare advantage hmo Insertion of radiation therapy devices in prostate gland for radiation therapy guidance cpt 55876 1103.22 1103.22 1103.22 1103.22 41954.78 41954.78 34962.32 34962.32 O 1103.22 1103.22 humana medicare advantage pos Insertion of radiation therapy devices in prostate gland for radiation therapy guidance cpt 55876 1103.22 1103.22 1103.22 1103.22 41954.78 41954.78 34962.32 34962.32 O 1103.22 1103.22 humana medicare advantage ppo Insertion of radiation therapy devices in prostate gland for radiation therapy guidance cpt 55876 1103.22 1103.22 1103.22 1103.22 41954.78 41954.78 34962.32 34962.32 O 1103.22 1103.22 humana medicare advantage hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 474.34 474.34 humana medicare advantage hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 474.34 474.34 humana medicare advantage pos diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 474.34 474.34 humana medicare advantage ppo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 474.34 474.34 humana medicare advantage hmo Electro-removal of prostate through bladder canal (urethra) with control of bleeding using an endoscope cpt 52601 3688.73 3688.73 3525.75 3525.75 28529.81 28529.81 23774.84 23774.84 O 3680.94 3680.94 humana medicare advantage hmo Electro-removal of prostate through bladder canal (urethra) with control of bleeding using an endoscope cpt 52601 3688.73 3688.73 3525.75 3525.75 28529.81 28529.81 23774.84 23774.84 O 3680.94 3680.94 humana medicare advantage pos Electro-removal of prostate through bladder canal (urethra) with control of bleeding using an endoscope cpt 52601 3688.73 3688.73 3525.75 3525.75 28529.81 28529.81 23774.84 23774.84 O 3680.94 3680.94 humana medicare advantage ppo Electro-removal of prostate through bladder canal (urethra) with control of bleeding using an endoscope cpt 52601 3688.73 3688.73 3525.75 3525.75 28529.81 28529.81 23774.84 23774.84 O 3680.94 3680.94 humana medicare advantage hmo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 665.73 665.73 humana medicare advantage hmo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 665.73 665.73 humana medicare advantage pos inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 665.73 665.73 humana medicare advantage ppo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 665.73 665.73 humana medicare advantage hmo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 3679.64 3679.64 humana medicare advantage hmo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 3679.64 3679.64 humana medicare advantage pos Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 3679.64 3679.64 humana medicare advantage ppo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 8848.19 8848.19 3451.31 3451.31 26122.61 26122.61 21768.84 21768.84 O 3679.64 3679.64 humana medicare advantage hmo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 3748.71 3748.71 3748.71 3748.71 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage hmo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 3748.71 3748.71 3748.71 3748.71 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage pos Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 3748.71 3748.71 3748.71 3748.71 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage ppo Crushing of stone in urinary duct (ureter) with stent using an endoscope cpt 52356 3748.71 3748.71 3748.71 3748.71 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 7649.74 7649.74 humana medicare advantage hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 7649.74 7649.74 humana medicare advantage pos fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 7649.74 7649.74 humana medicare advantage ppo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 7649.74 7649.74 humana medicare advantage hmo Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 2674.06 2674.06 humana medicare advantage hmo Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 2674.06 2674.06 humana medicare advantage pos Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 2674.06 2674.06 humana medicare advantage ppo Insertion of stent in urinary duct (ureter) using an endoscope cpt 52332 4436.99 4436.99 2466.29 2466.29 26802.56 26802.56 22335.47 22335.47 O 2674.06 2674.06 humana medicare advantage hmo Dilation of bladder canal (urethra) using an endoscope cpt 52281 1569.38 1569.38 1569.38 1569.38 15026.72 15026.72 12522.27 12522.27 O 1569.38 1569.38 humana medicare advantage hmo Dilation of bladder canal (urethra) using an endoscope cpt 52281 1569.38 1569.38 1569.38 1569.38 15026.72 15026.72 12522.27 12522.27 O 1569.38 1569.38 humana medicare advantage pos Dilation of bladder canal (urethra) using an endoscope cpt 52281 1569.38 1569.38 1569.38 1569.38 15026.72 15026.72 12522.27 12522.27 O 1569.38 1569.38 humana medicare advantage ppo Dilation of bladder canal (urethra) using an endoscope cpt 52281 1569.38 1569.38 1569.38 1569.38 15026.72 15026.72 12522.27 12522.27 O 1569.38 1569.38 humana medicare advantage hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage pos inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 48.73 48.73 humana medicare advantage hmo Destruction and/or removal of large growths of the bladder using an endoscope cpt 52240 3748.71 3748.71 3680.94 3680.94 24722.98 24722.98 20602.48 20602.48 O 3680.94 3680.94 humana medicare advantage hmo Destruction and/or removal of large growths of the bladder using an endoscope cpt 52240 3748.71 3748.71 3680.94 3680.94 24722.98 24722.98 20602.48 20602.48 O 3680.94 3680.94 humana medicare advantage pos Destruction and/or removal of large growths of the bladder using an endoscope cpt 52240 3748.71 3748.71 3680.94 3680.94 24722.98 24722.98 20602.48 20602.48 O 3680.94 3680.94 humana medicare advantage ppo Destruction and/or removal of large growths of the bladder using an endoscope cpt 52240 3748.71 3748.71 3680.94 3680.94 24722.98 24722.98 20602.48 20602.48 O 3680.94 3680.94 humana medicare advantage hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1913.09 1913.09 humana medicare advantage hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1913.09 1913.09 humana medicare advantage pos inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1913.09 1913.09 humana medicare advantage ppo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 1913.09 1913.09 humana medicare advantage hmo Instillation of anti-cancer drug into bladder cpt 51720 3748.71 3748.71 2631.27 2631.27 24225.89 24225.89 20188.24 20188.24 O 3748.71 3748.71 humana medicare advantage hmo Instillation of anti-cancer drug into bladder cpt 51720 3748.71 3748.71 2631.27 2631.27 24225.89 24225.89 20188.24 20188.24 O 3748.71 3748.71 humana medicare advantage pos Instillation of anti-cancer drug into bladder cpt 51720 3748.71 3748.71 2631.27 2631.27 24225.89 24225.89 20188.24 20188.24 O 3748.71 3748.71 humana medicare advantage ppo Instillation of anti-cancer drug into bladder cpt 51720 3748.71 3748.71 2631.27 2631.27 24225.89 24225.89 20188.24 20188.24 O 3748.71 3748.71 humana medicare advantage hmo "Insertion of indwelling bladder catheter, simple" cpt 51702 1952.13 1952.13 241.84 241.84 6324.92 6324.92 5270.77 5270.77 E 1952.13 1952.13 humana medicare advantage hmo "Insertion of indwelling bladder catheter, simple" cpt 51702 1952.13 1952.13 241.84 241.84 6324.92 6324.92 5270.77 5270.77 E 1952.13 1952.13 humana medicare advantage pos "Insertion of indwelling bladder catheter, simple" cpt 51702 1952.13 1952.13 241.84 241.84 6324.92 6324.92 5270.77 5270.77 E 1952.13 1952.13 humana medicare advantage ppo "Insertion of indwelling bladder catheter, simple" cpt 51702 1952.13 1952.13 241.84 241.84 6324.92 6324.92 5270.77 5270.77 E 1952.13 1952.13 humana medicare advantage hmo Insertion of temporary bladder catheter cpt 51701 1979.81 1979.81 754.97 754.97 7201.2 7201.2 6001 6001 E 1979.81 1979.81 humana medicare advantage hmo Insertion of temporary bladder catheter cpt 51701 1979.81 1979.81 754.97 754.97 7201.2 7201.2 6001 6001 E 1979.81 1979.81 humana medicare advantage pos Insertion of temporary bladder catheter cpt 51701 1979.81 1979.81 754.97 754.97 7201.2 7201.2 6001 6001 E 1979.81 1979.81 humana medicare advantage ppo Insertion of temporary bladder catheter cpt 51701 1979.81 1979.81 754.97 754.97 7201.2 7201.2 6001 6001 E 1979.81 1979.81 humana medicare advantage hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 4187.14 4187.14 humana medicare advantage hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 4187.14 4187.14 humana medicare advantage pos furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 4187.14 4187.14 humana medicare advantage ppo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 4187.14 4187.14 humana medicare advantage hmo Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 2626.48 2626.48 humana medicare advantage hmo Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 2626.48 2626.48 humana medicare advantage pos Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 2626.48 2626.48 humana medicare advantage ppo Shock wave crushing of kidney stones cpt 50590 11999.48 11999.48 2548.78 2548.78 29214.35 29214.35 24345.29 24345.29 O 2626.48 2626.48 humana medicare advantage hmo "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7309.85 7309.85 humana medicare advantage hmo "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7309.85 7309.85 humana medicare advantage pos "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7309.85 7309.85 humana medicare advantage ppo "Repair of incisional hernia using an endoscope, initial or primary" cpt 49654 7600.98 7600.98 6846.43 6846.43 32178.7 32178.7 26815.58 26815.58 O 7309.85 7309.85 humana medicare advantage hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 humana medicare advantage hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 humana medicare advantage pos Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 humana medicare advantage ppo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 humana medicare advantage hmo "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 1176.54 1176.54 humana medicare advantage hmo "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 1176.54 1176.54 humana medicare advantage pos "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 1176.54 1176.54 humana medicare advantage ppo "Contrast injections for x-ray imaging through existing tube in stomach, small bowel or large bowel, accessed through skin" cpt 49465 1176.54 1176.54 284.66 284.66 2474.03 2474.03 2061.69 2061.69 E 1176.54 1176.54 humana medicare advantage hmo Insertion of abdominal cavity catheter using an endoscope cpt 49324 4282.09 4282.09 3925.09 3925.09 21801.68 21801.68 18168.07 18168.07 O 4282.09 4282.09 humana medicare advantage hmo Insertion of abdominal cavity catheter using an endoscope cpt 49324 4282.09 4282.09 3925.09 3925.09 21801.68 21801.68 18168.07 18168.07 O 4282.09 4282.09 humana medicare advantage pos Insertion of abdominal cavity catheter using an endoscope cpt 49324 4282.09 4282.09 3925.09 3925.09 21801.68 21801.68 18168.07 18168.07 O 4282.09 4282.09 humana medicare advantage ppo Insertion of abdominal cavity catheter using an endoscope cpt 49324 4282.09 4282.09 3925.09 3925.09 21801.68 21801.68 18168.07 18168.07 O 4282.09 4282.09 humana medicare advantage hmo "Needle biopsy of abdominal cavity growth, accessed through the skin" cpt 49180 1215.96 1215.96 1199.67 1199.67 9084.9 9084.9 7570.75 7570.75 O 1215.96 1215.96 humana medicare advantage hmo "Needle biopsy of abdominal cavity growth, accessed through the skin" cpt 49180 1215.96 1215.96 1199.67 1199.67 9084.9 9084.9 7570.75 7570.75 O 1215.96 1215.96 humana medicare advantage pos "Needle biopsy of abdominal cavity growth, accessed through the skin" cpt 49180 1215.96 1215.96 1199.67 1199.67 9084.9 9084.9 7570.75 7570.75 O 1215.96 1215.96 humana medicare advantage ppo "Needle biopsy of abdominal cavity growth, accessed through the skin" cpt 49180 1215.96 1215.96 1199.67 1199.67 9084.9 9084.9 7570.75 7570.75 O 1215.96 1215.96 humana medicare advantage hmo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 2769.52 2769.52 889.02 889.02 10792.44 10792.44 8993.7 8993.7 E 2769.52 2769.52 humana medicare advantage hmo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 2769.52 2769.52 889.02 889.02 10792.44 10792.44 8993.7 8993.7 E 2769.52 2769.52 humana medicare advantage pos Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 2769.52 2769.52 889.02 889.02 10792.44 10792.44 8993.7 8993.7 E 2769.52 2769.52 humana medicare advantage ppo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 2769.52 2769.52 889.02 889.02 10792.44 10792.44 8993.7 8993.7 E 2769.52 2769.52 humana medicare advantage hmo Drainage of fluid from abdominal cavity cpt 49082 2769.52 2769.52 1596.53 1596.53 8858.04 8858.04 7381.7 7381.7 E 2769.52 2769.52 humana medicare advantage hmo Drainage of fluid from abdominal cavity cpt 49082 2769.52 2769.52 1596.53 1596.53 8858.04 8858.04 7381.7 7381.7 E 2769.52 2769.52 humana medicare advantage pos Drainage of fluid from abdominal cavity cpt 49082 2769.52 2769.52 1596.53 1596.53 8858.04 8858.04 7381.7 7381.7 E 2769.52 2769.52 humana medicare advantage ppo Drainage of fluid from abdominal cavity cpt 49082 2769.52 2769.52 1596.53 1596.53 8858.04 8858.04 7381.7 7381.7 E 2769.52 2769.52 humana medicare advantage hmo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 4242.22 4242.22 humana medicare advantage hmo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 4242.22 4242.22 humana medicare advantage pos Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 4242.22 4242.22 humana medicare advantage ppo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 4242.22 4242.22 humana medicare advantage hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 2425.05 2425.05 humana medicare advantage hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 2425.05 2425.05 humana medicare advantage pos phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 2425.05 2425.05 humana medicare advantage ppo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 2425.05 2425.05 humana medicare advantage hmo "Needle biopsy of liver, accessed through the skin" cpt 47000 1559.48 1559.48 1215.96 1215.96 10715.04 10715.04 8929.2 8929.2 O 1215.96 1215.96 humana medicare advantage hmo "Needle biopsy of liver, accessed through the skin" cpt 47000 1559.48 1559.48 1215.96 1215.96 10715.04 10715.04 8929.2 8929.2 O 1215.96 1215.96 humana medicare advantage pos "Needle biopsy of liver, accessed through the skin" cpt 47000 1559.48 1559.48 1215.96 1215.96 10715.04 10715.04 8929.2 8929.2 O 1215.96 1215.96 humana medicare advantage ppo "Needle biopsy of liver, accessed through the skin" cpt 47000 1559.48 1559.48 1215.96 1215.96 10715.04 10715.04 8929.2 8929.2 O 1215.96 1215.96 humana medicare advantage hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4579.24 4579.24 humana medicare advantage hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4579.24 4579.24 humana medicare advantage pos palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4579.24 4579.24 humana medicare advantage ppo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4579.24 4579.24 humana medicare advantage hmo Stapling of internal hemorrhoid cpt 46947 2076.66 2076.66 2076.66 2076.66 21249.76 21249.76 17708.13 17708.13 O 2076.66 2076.66 humana medicare advantage hmo Stapling of internal hemorrhoid cpt 46947 2076.66 2076.66 2076.66 2076.66 21249.76 21249.76 17708.13 17708.13 O 2076.66 2076.66 humana medicare advantage pos Stapling of internal hemorrhoid cpt 46947 2076.66 2076.66 2076.66 2076.66 21249.76 21249.76 17708.13 17708.13 O 2076.66 2076.66 humana medicare advantage ppo Stapling of internal hemorrhoid cpt 46947 2076.66 2076.66 2076.66 2076.66 21249.76 21249.76 17708.13 17708.13 O 2076.66 2076.66 humana medicare advantage hmo Removal of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46320 979.27 979.27 898.18 898.18 1077.82 1077.82 898.18 898.18 E 898.18 898.18 humana medicare advantage hmo Removal of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46320 979.27 979.27 898.18 898.18 1077.82 1077.82 898.18 898.18 E 898.18 898.18 humana medicare advantage pos Removal of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46320 979.27 979.27 898.18 898.18 1077.82 1077.82 898.18 898.18 E 898.18 898.18 humana medicare advantage ppo Removal of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46320 979.27 979.27 898.18 898.18 1077.82 1077.82 898.18 898.18 E 898.18 898.18 humana medicare advantage hmo Removal of single external and internal hemorrhoid group cpt 46255 2076.66 2076.66 1557.5 1557.5 16490.1 16490.1 13741.75 13741.75 O 2076.66 2076.66 humana medicare advantage hmo Removal of single external and internal hemorrhoid group cpt 46255 2076.66 2076.66 1557.5 1557.5 16490.1 16490.1 13741.75 13741.75 O 2076.66 2076.66 humana medicare advantage pos Removal of single external and internal hemorrhoid group cpt 46255 2076.66 2076.66 1557.5 1557.5 16490.1 16490.1 13741.75 13741.75 O 2076.66 2076.66 humana medicare advantage ppo Removal of single external and internal hemorrhoid group cpt 46255 2076.66 2076.66 1557.5 1557.5 16490.1 16490.1 13741.75 13741.75 O 2076.66 2076.66 humana medicare advantage hmo Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 405.94 405.94 humana medicare advantage hmo Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 405.94 405.94 humana medicare advantage pos Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 405.94 405.94 humana medicare advantage ppo Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 405.94 405.94 humana medicare advantage hmo "Drainage of rectal abscess, superficial, surrounding the anus" cpt 46050 874.56 874.56 798.85 798.85 1153.27 1153.27 961.06 961.06 E 874.56 874.56 humana medicare advantage hmo "Drainage of rectal abscess, superficial, surrounding the anus" cpt 46050 874.56 874.56 798.85 798.85 1153.27 1153.27 961.06 961.06 E 874.56 874.56 humana medicare advantage pos "Drainage of rectal abscess, superficial, surrounding the anus" cpt 46050 874.56 874.56 798.85 798.85 1153.27 1153.27 961.06 961.06 E 874.56 874.56 humana medicare advantage ppo "Drainage of rectal abscess, superficial, surrounding the anus" cpt 46050 874.56 874.56 798.85 798.85 1153.27 1153.27 961.06 961.06 E 874.56 874.56 humana medicare advantage hmo "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1307.74 1307.74 humana medicare advantage hmo "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1307.74 1307.74 humana medicare advantage pos "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1307.74 1307.74 humana medicare advantage ppo "Injections beneath lining of large bowel, using a flexible endoscope" cpt 45381 1913.87 1913.87 1240.48 1240.48 6346.84 6346.84 5289.03 5289.03 O 1307.74 1307.74 humana medicare advantage hmo Biopsy of the lower large bowel using an endoscope (sigmoidoscopy) cpt 45331 1034.59 1034.59 692.36 692.36 4956.14 4956.14 4130.12 4130.12 O 1034.59 1034.59 humana medicare advantage hmo Biopsy of the lower large bowel using an endoscope (sigmoidoscopy) cpt 45331 1034.59 1034.59 692.36 692.36 4956.14 4956.14 4130.12 4130.12 O 1034.59 1034.59 humana medicare advantage pos Biopsy of the lower large bowel using an endoscope (sigmoidoscopy) cpt 45331 1034.59 1034.59 692.36 692.36 4956.14 4956.14 4130.12 4130.12 O 1034.59 1034.59 humana medicare advantage ppo Biopsy of the lower large bowel using an endoscope (sigmoidoscopy) cpt 45331 1034.59 1034.59 692.36 692.36 4956.14 4956.14 4130.12 4130.12 O 1034.59 1034.59 humana medicare advantage hmo methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1913.09 1913.09 humana medicare advantage hmo methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1913.09 1913.09 humana medicare advantage pos methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1913.09 1913.09 humana medicare advantage ppo methylprednisolone injection cpt J2920 2485.45 2485.45 1913.09 1913.09 13577.17 13577.17 11314.31 11314.31 E 1913.09 1913.09 humana medicare advantage hmo Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 676.71 676.71 humana medicare advantage hmo Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 676.71 676.71 humana medicare advantage pos Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 676.71 676.71 humana medicare advantage ppo Diagnostic examination of the lower portion of the large bowel using an endoscope cpt 45330 2049.34 2049.34 676.71 676.71 3987.61 3987.61 3323.01 3323.01 O 676.71 676.71 humana medicare advantage hmo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 4579.24 4579.24 humana medicare advantage hmo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 4579.24 4579.24 humana medicare advantage pos alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 4579.24 4579.24 humana medicare advantage ppo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 4579.24 4579.24 humana medicare advantage hmo Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 1176.54 1176.54 humana medicare advantage hmo Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 1176.54 1176.54 humana medicare advantage pos Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 1176.54 1176.54 humana medicare advantage ppo Replacement of stomach stoma tube accessed through skin cpt 43762 1176.54 1176.54 399.44 399.44 2354.66 2354.66 1962.22 1962.22 E 1176.54 1176.54 humana medicare advantage hmo Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 7453.01 7453.01 humana medicare advantage hmo Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 7453.01 7453.01 humana medicare advantage pos Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 7453.01 7453.01 humana medicare advantage ppo Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 7453.01 7453.01 humana medicare advantage hmo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 humana medicare advantage hmo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 humana medicare advantage pos "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 humana medicare advantage ppo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 humana medicare advantage hmo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 1044.35 1044.35 humana medicare advantage hmo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 1044.35 1044.35 humana medicare advantage pos Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 1044.35 1044.35 humana medicare advantage ppo Insertion of guide wire with dilation of esophagus using an endoscope cpt 43248 2442.65 2442.65 685.69 685.69 4299.44 4299.44 3582.87 3582.87 O 1044.35 1044.35 humana medicare advantage hmo thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 1958.83 1958.83 humana medicare advantage hmo thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 1958.83 1958.83 humana medicare advantage pos thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 1958.83 1958.83 humana medicare advantage ppo thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 1958.83 1958.83 humana medicare advantage hmo vitamin b12 injection cpt J3420 2121.81 2121.81 2121.81 2121.81 21812.96 21812.96 18177.47 18177.47 E 2121.81 2121.81 humana medicare advantage hmo vitamin b12 injection cpt J3420 2121.81 2121.81 2121.81 2121.81 21812.96 21812.96 18177.47 18177.47 E 2121.81 2121.81 humana medicare advantage pos vitamin b12 injection cpt J3420 2121.81 2121.81 2121.81 2121.81 21812.96 21812.96 18177.47 18177.47 E 2121.81 2121.81 humana medicare advantage ppo vitamin b12 injection cpt J3420 2121.81 2121.81 2121.81 2121.81 21812.96 21812.96 18177.47 18177.47 E 2121.81 2121.81 humana medicare advantage hmo vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 2371.01 2371.01 humana medicare advantage hmo vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 2371.01 2371.01 humana medicare advantage pos vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 2371.01 2371.01 humana medicare advantage ppo vitamin b12 injection cpt J3420 15987.99 15987.99 53.57 53.57 475.2 475.2 396 396 O 2371.01 2371.01 humana medicare advantage hmo Examination of chest using an endoscope with lymph node biopsy cpt 39402 4282.09 4282.09 4213.58 4213.58 23534.24 23534.24 19611.87 19611.87 O 4282.09 4282.09 humana medicare advantage hmo Examination of chest using an endoscope with lymph node biopsy cpt 39402 4282.09 4282.09 4213.58 4213.58 23534.24 23534.24 19611.87 19611.87 O 4282.09 4282.09 humana medicare advantage pos Examination of chest using an endoscope with lymph node biopsy cpt 39402 4282.09 4282.09 4213.58 4213.58 23534.24 23534.24 19611.87 19611.87 O 4282.09 4282.09 humana medicare advantage ppo Examination of chest using an endoscope with lymph node biopsy cpt 39402 4282.09 4282.09 4213.58 4213.58 23534.24 23534.24 19611.87 19611.87 O 4282.09 4282.09 humana medicare advantage hmo Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 4639.61 4639.61 humana medicare advantage hmo Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 4639.61 4639.61 humana medicare advantage pos Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 4639.61 4639.61 humana medicare advantage ppo Injection of radioactive dye for X-ray identification of lymph node cpt 38792 8915.14 8915.14 326.12 326.12 31558.91 31558.91 26299.09 26299.09 O 4639.61 4639.61 humana medicare advantage hmo "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 2636.04 2636.04 humana medicare advantage hmo "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 2636.04 2636.04 humana medicare advantage pos "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 2636.04 2636.04 humana medicare advantage ppo "Biopsy or removal of lymph nodes of under the arm, open procedure" cpt 38525 4565.38 4565.38 2636.04 2636.04 28090.33 28090.33 23408.61 23408.61 O 2636.04 2636.04 humana medicare advantage hmo "Biopsy or removal of lymph nodes of neck, open procedure" cpt 38510 4565.38 4565.38 2640.88 2640.88 17878.4 17878.4 14898.67 14898.67 O 2683.82 2683.82 humana medicare advantage hmo "Biopsy or removal of lymph nodes of neck, open procedure" cpt 38510 4565.38 4565.38 2640.88 2640.88 17878.4 17878.4 14898.67 14898.67 O 2683.82 2683.82 humana medicare advantage pos "Biopsy or removal of lymph nodes of neck, open procedure" cpt 38510 4565.38 4565.38 2640.88 2640.88 17878.4 17878.4 14898.67 14898.67 O 2683.82 2683.82 humana medicare advantage ppo "Biopsy or removal of lymph nodes of neck, open procedure" cpt 38510 4565.38 4565.38 2640.88 2640.88 17878.4 17878.4 14898.67 14898.67 O 2683.82 2683.82 humana medicare advantage hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 4187.14 4187.14 humana medicare advantage hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 4187.14 4187.14 humana medicare advantage pos normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 4187.14 4187.14 humana medicare advantage ppo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 4187.14 4187.14 humana medicare advantage hmo "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 4639.61 4639.61 humana medicare advantage hmo "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 4639.61 4639.61 humana medicare advantage pos "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 4639.61 4639.61 humana medicare advantage ppo "Biopsy or removal of lymph nodes, open procedure" cpt 38500 8915.14 8915.14 4565.38 4565.38 29275.99 29275.99 24396.66 24396.66 O 4639.61 4639.61 humana medicare advantage hmo Tying incision and/or removal of varicose vein clusters of leg cpt 37785 982.25 982.25 982.25 982.25 1178.7 1178.7 982.25 982.25 E 982.25 982.25 humana medicare advantage hmo Tying incision and/or removal of varicose vein clusters of leg cpt 37785 982.25 982.25 982.25 982.25 1178.7 1178.7 982.25 982.25 E 982.25 982.25 humana medicare advantage pos Tying incision and/or removal of varicose vein clusters of leg cpt 37785 982.25 982.25 982.25 982.25 1178.7 1178.7 982.25 982.25 E 982.25 982.25 humana medicare advantage ppo Tying incision and/or removal of varicose vein clusters of leg cpt 37785 982.25 982.25 982.25 982.25 1178.7 1178.7 982.25 982.25 E 982.25 982.25 humana medicare advantage hmo "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 2455.02 2455.02 humana medicare advantage hmo "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 2455.02 2455.02 humana medicare advantage pos "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 2455.02 2455.02 humana medicare advantage ppo "Multiple incisions for removal of varicose veins of arm or leg, greater than 20 incisions" cpt 37766 12086.89 12086.89 2455.02 2455.02 24402.41 24402.41 20335.34 20335.34 O 2455.02 2455.02 humana medicare advantage hmo "Multiple incisions for removal of varicose veins of arm or leg, 10-20 incisions" cpt 37765 2455.02 2455.02 2455.02 2455.02 21291.67 21291.67 17743.06 17743.06 O 2455.02 2455.02 humana medicare advantage hmo "Multiple incisions for removal of varicose veins of arm or leg, 10-20 incisions" cpt 37765 2455.02 2455.02 2455.02 2455.02 21291.67 21291.67 17743.06 17743.06 O 2455.02 2455.02 humana medicare advantage pos "Multiple incisions for removal of varicose veins of arm or leg, 10-20 incisions" cpt 37765 2455.02 2455.02 2455.02 2455.02 21291.67 21291.67 17743.06 17743.06 O 2455.02 2455.02 humana medicare advantage ppo "Multiple incisions for removal of varicose veins of arm or leg, 10-20 incisions" cpt 37765 2455.02 2455.02 2455.02 2455.02 21291.67 21291.67 17743.06 17743.06 O 2455.02 2455.02 humana medicare advantage hmo "Ultrasound evaluation of blood vessel during diagnosis or treatment, initial vessel" cpt 37252 14120.9 14120.9 8777.72 8777.72 104458.68 104458.68 87048.9 87048.9 O 14120.9 14120.9 humana medicare advantage hmo "Ultrasound evaluation of blood vessel during diagnosis or treatment, initial vessel" cpt 37252 14120.9 14120.9 8777.72 8777.72 104458.68 104458.68 87048.9 87048.9 O 14120.9 14120.9 humana medicare advantage pos "Ultrasound evaluation of blood vessel during diagnosis or treatment, initial vessel" cpt 37252 14120.9 14120.9 8777.72 8777.72 104458.68 104458.68 87048.9 87048.9 O 14120.9 14120.9 humana medicare advantage ppo "Ultrasound evaluation of blood vessel during diagnosis or treatment, initial vessel" cpt 37252 14120.9 14120.9 8777.72 8777.72 104458.68 104458.68 87048.9 87048.9 O 14120.9 14120.9 humana medicare advantage hmo "Balloon dilation of artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37232 14120.9 14120.9 8646.05 8646.05 93086.88 93086.88 77572.4 77572.4 O 8646.05 8646.05 humana medicare advantage hmo "Balloon dilation of artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37232 14120.9 14120.9 8646.05 8646.05 93086.88 93086.88 77572.4 77572.4 O 8646.05 8646.05 humana medicare advantage pos "Balloon dilation of artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37232 14120.9 14120.9 8646.05 8646.05 93086.88 93086.88 77572.4 77572.4 O 8646.05 8646.05 humana medicare advantage ppo "Balloon dilation of artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37232 14120.9 14120.9 8646.05 8646.05 93086.88 93086.88 77572.4 77572.4 O 8646.05 8646.05 humana medicare advantage hmo "Removal of plaque and insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37231 14120.9 14120.9 14120.9 14120.9 145342 145342 121118.33 121118.33 O 14120.9 14120.9 humana medicare advantage hmo "Removal of plaque and insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37231 14120.9 14120.9 14120.9 14120.9 145342 145342 121118.33 121118.33 O 14120.9 14120.9 humana medicare advantage pos "Removal of plaque and insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37231 14120.9 14120.9 14120.9 14120.9 145342 145342 121118.33 121118.33 O 14120.9 14120.9 humana medicare advantage ppo "Removal of plaque and insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37231 14120.9 14120.9 14120.9 14120.9 145342 145342 121118.33 121118.33 O 14120.9 14120.9 humana medicare advantage hmo "Insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37230 14120.9 14120.9 14007.94 14007.94 90677.59 90677.59 75564.66 75564.66 O 14007.94 14007.94 humana medicare advantage hmo "Insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37230 14120.9 14120.9 14007.94 14007.94 90677.59 90677.59 75564.66 75564.66 O 14007.94 14007.94 humana medicare advantage pos "Insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37230 14120.9 14120.9 14007.94 14007.94 90677.59 90677.59 75564.66 75564.66 O 14007.94 14007.94 humana medicare advantage ppo "Insertion of stents into artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37230 14120.9 14120.9 14007.94 14007.94 90677.59 90677.59 75564.66 75564.66 O 14007.94 14007.94 humana medicare advantage hmo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 11383.48 11383.48 humana medicare advantage hmo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 11383.48 11383.48 humana medicare advantage pos "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 11383.48 11383.48 humana medicare advantage ppo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 11383.48 11383.48 humana medicare advantage hmo "Insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37226 14007.94 14007.94 8097.07 8097.07 92080.52 92080.52 76733.77 76733.77 O 14007.94 14007.94 humana medicare advantage hmo "Insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37226 14007.94 14007.94 8097.07 8097.07 92080.52 92080.52 76733.77 76733.77 O 14007.94 14007.94 humana medicare advantage pos "Insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37226 14007.94 14007.94 8097.07 8097.07 92080.52 92080.52 76733.77 76733.77 O 14007.94 14007.94 humana medicare advantage ppo "Insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37226 14007.94 14007.94 8097.07 8097.07 92080.52 92080.52 76733.77 76733.77 O 14007.94 14007.94 humana medicare advantage hmo "Removal of plaque in arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37225 11449.31 11449.31 8704.03 8704.03 78604.32 78604.32 65503.6 65503.6 O 11449.31 11449.31 humana medicare advantage hmo "Removal of plaque in arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37225 11449.31 11449.31 8704.03 8704.03 78604.32 78604.32 65503.6 65503.6 O 11449.31 11449.31 humana medicare advantage pos "Removal of plaque in arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37225 11449.31 11449.31 8704.03 8704.03 78604.32 78604.32 65503.6 65503.6 O 11449.31 11449.31 humana medicare advantage ppo "Removal of plaque in arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37225 11449.31 11449.31 8704.03 8704.03 78604.32 78604.32 65503.6 65503.6 O 11449.31 11449.31 humana medicare advantage hmo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 7700.07 7700.07 humana medicare advantage hmo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 7700.07 7700.07 humana medicare advantage pos bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 7700.07 7700.07 humana medicare advantage ppo bevacizumab injection cpt J9035 8590.23 8590.23 3858.86 3858.86 21437.02 21437.02 17864.18 17864.18 O 7700.07 7700.07 humana medicare advantage hmo "Balloon dilation of arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37224 8630.33 8630.33 4023.57 4023.57 44426.34 44426.34 37021.95 37021.95 O 6517.31 6517.31 humana medicare advantage hmo "Balloon dilation of arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37224 8630.33 8630.33 4023.57 4023.57 44426.34 44426.34 37021.95 37021.95 O 6517.31 6517.31 humana medicare advantage pos "Balloon dilation of arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37224 8630.33 8630.33 4023.57 4023.57 44426.34 44426.34 37021.95 37021.95 O 6517.31 6517.31 humana medicare advantage ppo "Balloon dilation of arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37224 8630.33 8630.33 4023.57 4023.57 44426.34 44426.34 37021.95 37021.95 O 6517.31 6517.31 humana medicare advantage hmo "Insertion of stents in artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37221 8777.72 8777.72 8185.32 8185.32 62575.42 62575.42 52146.18 52146.18 O 8603.97 8603.97 humana medicare advantage hmo "Insertion of stents in artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37221 8777.72 8777.72 8185.32 8185.32 62575.42 62575.42 52146.18 52146.18 O 8603.97 8603.97 humana medicare advantage pos "Insertion of stents in artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37221 8777.72 8777.72 8185.32 8185.32 62575.42 62575.42 52146.18 52146.18 O 8603.97 8603.97 humana medicare advantage ppo "Insertion of stents in artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37221 8777.72 8777.72 8185.32 8185.32 62575.42 62575.42 52146.18 52146.18 O 8603.97 8603.97 humana medicare advantage hmo "inj., velcade 0.1 mg" cpt J9041 1206.33 1206.33 1184.61 1184.61 8626.8 8626.8 7189 7189 O 1204.76 1204.76 humana medicare advantage hmo "inj., velcade 0.1 mg" cpt J9041 1206.33 1206.33 1184.61 1184.61 8626.8 8626.8 7189 7189 O 1204.76 1204.76 humana medicare advantage pos "inj., velcade 0.1 mg" cpt J9041 1206.33 1206.33 1184.61 1184.61 8626.8 8626.8 7189 7189 O 1204.76 1204.76 humana medicare advantage ppo "inj., velcade 0.1 mg" cpt J9041 1206.33 1206.33 1184.61 1184.61 8626.8 8626.8 7189 7189 O 1204.76 1204.76 humana medicare advantage hmo "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8646.05 8646.05 humana medicare advantage hmo "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8646.05 8646.05 humana medicare advantage pos "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8646.05 8646.05 humana medicare advantage ppo "Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure" cpt 37220 8646.05 8646.05 6509.45 6509.45 57926.81 57926.81 48272.34 48272.34 O 8646.05 8646.05 humana medicare advantage hmo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 7649.74 7649.74 humana medicare advantage hmo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 7649.74 7649.74 humana medicare advantage pos carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 7649.74 7649.74 humana medicare advantage ppo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 7649.74 7649.74 humana medicare advantage hmo "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 1444.99 1444.99 humana medicare advantage hmo "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 1444.99 1444.99 humana medicare advantage pos "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 1444.99 1444.99 humana medicare advantage ppo "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 1444.99 1444.99 humana medicare advantage hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 224.22 224.22 humana medicare advantage hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 224.22 224.22 humana medicare advantage pos Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 224.22 224.22 humana medicare advantage ppo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 224.22 224.22 humana medicare advantage hmo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 368.79 368.79 humana medicare advantage hmo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 368.79 368.79 humana medicare advantage pos docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 368.79 368.79 humana medicare advantage ppo docetaxel injection cpt J9171 23772.44 23772.44 368.79 368.79 32313.89 32313.89 26928.24 26928.24 O 368.79 368.79 humana medicare advantage hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 2015.29 2015.29 humana medicare advantage hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 2015.29 2015.29 humana medicare advantage pos Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 2015.29 2015.29 humana medicare advantage ppo Arterial puncture withdrawal of blood for diagnosis cpt 36600 2015.29 2015.29 629.32 629.32 10125.67 10125.67 8438.06 8438.06 E 2015.29 2015.29 humana medicare advantage hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 928.87 928.87 humana medicare advantage hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 928.87 928.87 humana medicare advantage pos fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 928.87 928.87 humana medicare advantage ppo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 928.87 928.87 humana medicare advantage hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 5253.4 5253.4 humana medicare advantage hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 5253.4 5253.4 humana medicare advantage pos Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 5253.4 5253.4 humana medicare advantage ppo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 5253.4 5253.4 humana medicare advantage hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 808.19 808.19 797.7 797.7 3121.24 3121.24 2601.03 2601.03 E 797.7 797.7 humana medicare advantage hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 808.19 808.19 797.7 797.7 3121.24 3121.24 2601.03 2601.03 E 797.7 797.7 humana medicare advantage pos Declotting infusion of implanted central venous access device or catheter cpt 36593 808.19 808.19 797.7 797.7 3121.24 3121.24 2601.03 2601.03 E 797.7 797.7 humana medicare advantage ppo Declotting infusion of implanted central venous access device or catheter cpt 36593 808.19 808.19 797.7 797.7 3121.24 3121.24 2601.03 2601.03 E 797.7 797.7 humana medicare advantage hmo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7649.74 7649.74 humana medicare advantage hmo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7649.74 7649.74 humana medicare advantage pos in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7649.74 7649.74 humana medicare advantage ppo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7649.74 7649.74 humana medicare advantage hmo irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 928.87 928.87 humana medicare advantage hmo irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 928.87 928.87 humana medicare advantage pos irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 928.87 928.87 humana medicare advantage ppo irinotecan injection cpt J9206 8573.35 8573.35 928.87 928.87 23692.8 23692.8 19744 19744 O 928.87 928.87 humana medicare advantage hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1914.89 1914.89 humana medicare advantage hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1914.89 1914.89 humana medicare advantage pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1914.89 1914.89 humana medicare advantage ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1914.89 1914.89 humana medicare advantage hmo Collection of blood specimen from a completely implantable venous access device cpt 36591 10315.29 10315.29 96.59 96.59 697.24 697.24 581.03 581.03 O 96.59 96.59 humana medicare advantage hmo Collection of blood specimen from a completely implantable venous access device cpt 36591 10315.29 10315.29 96.59 96.59 697.24 697.24 581.03 581.03 O 96.59 96.59 humana medicare advantage pos Collection of blood specimen from a completely implantable venous access device cpt 36591 10315.29 10315.29 96.59 96.59 697.24 697.24 581.03 581.03 O 96.59 96.59 humana medicare advantage ppo Collection of blood specimen from a completely implantable venous access device cpt 36591 10315.29 10315.29 96.59 96.59 697.24 697.24 581.03 581.03 O 96.59 96.59 humana medicare advantage hmo Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 2455.02 2455.02 humana medicare advantage hmo Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 2455.02 2455.02 humana medicare advantage pos Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 2455.02 2455.02 humana medicare advantage ppo Removal of peripheral venous catheter for infusion cpt 36590 2455.02 2455.02 509.53 509.53 12704.36 12704.36 10586.97 10586.97 O 2455.02 2455.02 humana medicare advantage hmo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 451.73 451.73 humana medicare advantage hmo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 451.73 451.73 humana medicare advantage pos paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 451.73 451.73 humana medicare advantage ppo paclitaxel injection cpt J9267 2981.53 2981.53 429.12 429.12 4304.7 4304.7 3587.25 3587.25 O 451.73 451.73 humana medicare advantage hmo "Replacement of central venous catheter, tunneled without port or pump" cpt 36581 2455.02 2455.02 2353.39 2353.39 19733.89 19733.89 16444.91 16444.91 O 2455.02 2455.02 humana medicare advantage hmo "Replacement of central venous catheter, tunneled without port or pump" cpt 36581 2455.02 2455.02 2353.39 2353.39 19733.89 19733.89 16444.91 16444.91 O 2455.02 2455.02 humana medicare advantage pos "Replacement of central venous catheter, tunneled without port or pump" cpt 36581 2455.02 2455.02 2353.39 2353.39 19733.89 19733.89 16444.91 16444.91 O 2455.02 2455.02 humana medicare advantage ppo "Replacement of central venous catheter, tunneled without port or pump" cpt 36581 2455.02 2455.02 2353.39 2353.39 19733.89 19733.89 16444.91 16444.91 O 2455.02 2455.02 humana medicare advantage hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 7502.28 7502.28 humana medicare advantage hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 7502.28 7502.28 humana medicare advantage pos inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 7502.28 7502.28 humana medicare advantage ppo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 7502.28 7502.28 humana medicare advantage hmo "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 6636.16 6636.16 humana medicare advantage hmo "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 6636.16 6636.16 humana medicare advantage pos "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 6636.16 6636.16 humana medicare advantage ppo "Insertion of peripherally inserted central venous catheter for infusion (PICC), patient 5 years or older" cpt 36569 6636.16 6636.16 1333.15 1333.15 2981.17 2981.17 2484.31 2484.31 O 6636.16 6636.16 humana medicare advantage hmo "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 4996.45 4996.45 humana medicare advantage hmo "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 4996.45 4996.45 humana medicare advantage pos "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 4996.45 4996.45 humana medicare advantage ppo "injection, nivolumab" cpt J9299 16388.92 16388.92 3788.28 3788.28 29876.89 29876.89 24897.41 24897.41 O 4996.45 4996.45 humana medicare advantage hmo inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 4579.24 4579.24 humana medicare advantage hmo inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 4579.24 4579.24 humana medicare advantage pos inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 4579.24 4579.24 humana medicare advantage ppo inj. pemetrexed nos 10mg cpt J9305 17466.44 17466.44 4579.24 4579.24 68724.02 68724.02 57270.02 57270.02 O 4579.24 4579.24 humana medicare advantage hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 11362.44 11362.44 humana medicare advantage hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 11362.44 11362.44 humana medicare advantage pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 11362.44 11362.44 humana medicare advantage ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 11362.44 11362.44 humana medicare advantage hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2418.19 2418.19 humana medicare advantage hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2418.19 2418.19 humana medicare advantage pos "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2418.19 2418.19 humana medicare advantage ppo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2418.19 2418.19 humana medicare advantage hmo "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 6402.18 6402.18 humana medicare advantage hmo "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 6402.18 6402.18 humana medicare advantage pos "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 6402.18 6402.18 humana medicare advantage ppo "inj, ado-trastuzumab emt 1mg" cpt J9354 16776.17 16776.17 6402.18 6402.18 46690.63 46690.63 38908.86 38908.86 O 6402.18 6402.18 humana medicare advantage hmo "Insertion of central venous catheter for infusion, patient 5 years or older, tunneled" cpt 36558 2455.02 2455.02 2415.74 2415.74 20607.3 20607.3 17172.75 17172.75 O 2455.02 2455.02 humana medicare advantage hmo "Insertion of central venous catheter for infusion, patient 5 years or older, tunneled" cpt 36558 2455.02 2455.02 2415.74 2415.74 20607.3 20607.3 17172.75 17172.75 O 2455.02 2455.02 humana medicare advantage pos "Insertion of central venous catheter for infusion, patient 5 years or older, tunneled" cpt 36558 2455.02 2455.02 2415.74 2415.74 20607.3 20607.3 17172.75 17172.75 O 2455.02 2455.02 humana medicare advantage ppo "Insertion of central venous catheter for infusion, patient 5 years or older, tunneled" cpt 36558 2455.02 2455.02 2415.74 2415.74 20607.3 20607.3 17172.75 17172.75 O 2455.02 2455.02 humana medicare advantage hmo "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 humana medicare advantage hmo "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 humana medicare advantage pos "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 humana medicare advantage ppo "Insertion of central venous catheter for infusion, patient 5 years or older, not tunneled" cpt 36556 1719.81 1719.81 1444.99 1444.99 16238.96 16238.96 13532.47 13532.47 O 1444.99 1444.99 humana medicare advantage hmo "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 2455.02 2455.02 humana medicare advantage hmo "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 2455.02 2455.02 humana medicare advantage pos "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 2455.02 2455.02 humana medicare advantage ppo "Destruction of insufficient vein of arm or leg, accessed through the skin" cpt 36475 12086.89 12086.89 2415.74 2415.74 12086.68 12086.68 10072.23 10072.23 O 2455.02 2455.02 humana medicare advantage hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2939.47 2939.47 humana medicare advantage hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2939.47 2939.47 humana medicare advantage pos "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2939.47 2939.47 humana medicare advantage ppo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2939.47 2939.47 humana medicare advantage hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 978.45 978.45 humana medicare advantage hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 978.45 978.45 humana medicare advantage pos Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 978.45 978.45 humana medicare advantage ppo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 978.45 978.45 humana medicare advantage hmo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 283.05 283.05 humana medicare advantage hmo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 283.05 283.05 humana medicare advantage pos ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 283.05 283.05 humana medicare advantage ppo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 283.05 283.05 humana medicare advantage hmo non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 485.11 485.11 humana medicare advantage hmo non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 485.11 485.11 humana medicare advantage pos non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 485.11 485.11 humana medicare advantage ppo non-pneum walk boot pre cst cpt L4386 529.29 529.29 258.55 258.55 2156.71 2156.71 1797.26 1797.26 O 485.11 485.11 humana medicare advantage hmo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 2052.21 2052.21 humana medicare advantage hmo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 2052.21 2052.21 humana medicare advantage pos rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 2052.21 2052.21 humana medicare advantage ppo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 2052.21 2052.21 humana medicare advantage hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 707.85 707.85 humana medicare advantage hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 707.85 707.85 humana medicare advantage pos rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 707.85 707.85 humana medicare advantage ppo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 707.85 707.85 humana medicare advantage hmo platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 1109.83 1109.83 humana medicare advantage hmo platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 1109.83 1109.83 humana medicare advantage pos platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 1109.83 1109.83 humana medicare advantage ppo platelet pheres leukoreduced cpt P9035 2178.24 2178.24 1109.83 1109.83 5653.97 5653.97 4711.64 4711.64 O 1109.83 1109.83 humana medicare advantage hmo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 2052.21 2052.21 humana medicare advantage hmo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 2052.21 2052.21 humana medicare advantage pos Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 2052.21 2052.21 humana medicare advantage ppo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 2052.21 2052.21 humana medicare advantage hmo plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 1109.83 1109.83 humana medicare advantage hmo plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 1109.83 1109.83 humana medicare advantage pos plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 1109.83 1109.83 humana medicare advantage ppo plate pheres leukoredu irrad cpt P9037 2332.93 2332.93 1109.83 1109.83 5247.16 5247.16 4372.63 4372.63 O 1109.83 1109.83 humana medicare advantage hmo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 1055.25 1055.25 humana medicare advantage hmo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 1055.25 1055.25 humana medicare advantage pos rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 1055.25 1055.25 humana medicare advantage ppo rbc leukoreduced irradiated cpt P9040 2209.95 2209.95 606.52 606.52 3370.13 3370.13 2808.44 2808.44 O 1055.25 1055.25 humana medicare advantage hmo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 560.06 560.06 humana medicare advantage hmo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 560.06 560.06 humana medicare advantage pos "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 560.06 560.06 humana medicare advantage ppo "ferumoxytol, non-esrd" cpt Q0138 801.75 801.75 556.49 556.49 2883.62 2883.62 2403.02 2403.02 O 560.06 560.06 humana medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 408.55 408.55 humana medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 408.55 408.55 humana medicare advantage pos Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 408.55 408.55 humana medicare advantage ppo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 408.55 408.55 humana medicare advantage hmo fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 6636.16 6636.16 humana medicare advantage hmo fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 6636.16 6636.16 humana medicare advantage pos fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 6636.16 6636.16 humana medicare advantage ppo fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 6636.16 6636.16 humana medicare advantage hmo strattice tm cpt Q4130 2569.42 2569.42 2569.42 2569.42 29280.64 29280.64 24400.53 24400.53 O 2569.42 2569.42 humana medicare advantage hmo strattice tm cpt Q4130 2569.42 2569.42 2569.42 2569.42 29280.64 29280.64 24400.53 24400.53 O 2569.42 2569.42 humana medicare advantage pos strattice tm cpt Q4130 2569.42 2569.42 2569.42 2569.42 29280.64 29280.64 24400.53 24400.53 O 2569.42 2569.42 humana medicare advantage ppo strattice tm cpt Q4130 2569.42 2569.42 2569.42 2569.42 29280.64 29280.64 24400.53 24400.53 O 2569.42 2569.42 humana medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 881.79 881.79 humana medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 881.79 881.79 humana medicare advantage pos Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 881.79 881.79 humana medicare advantage ppo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 881.79 881.79 humana medicare advantage hmo inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 418.04 418.04 humana medicare advantage hmo inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 418.04 418.04 humana medicare advantage pos inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 418.04 418.04 humana medicare advantage ppo inj retacrit non-esrd use cpt Q5106 418.04 418.04 412.37 412.37 1567.1 1567.1 1305.92 1305.92 O 418.04 418.04 humana medicare advantage hmo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4309.68 4309.68 humana medicare advantage hmo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4309.68 4309.68 humana medicare advantage pos "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4309.68 4309.68 humana medicare advantage ppo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4309.68 4309.68 humana medicare advantage hmo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10448.12 10448.12 humana medicare advantage hmo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10448.12 10448.12 humana medicare advantage pos "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10448.12 10448.12 humana medicare advantage ppo "inj., kanjinti, 10 mg" cpt Q5117 10872.3 10872.3 3654.19 3654.19 21191.38 21191.38 17659.48 17659.48 O 10448.12 10448.12 humana medicare advantage hmo "inj octafluoropropane mic,ml" cpt Q9956 426.62 426.62 426.62 426.62 1209 1209 1007.5 1007.5 O 426.62 426.62 humana medicare advantage hmo "inj octafluoropropane mic,ml" cpt Q9956 426.62 426.62 426.62 426.62 1209 1209 1007.5 1007.5 O 426.62 426.62 humana medicare advantage pos "inj octafluoropropane mic,ml" cpt Q9956 426.62 426.62 426.62 426.62 1209 1209 1007.5 1007.5 O 426.62 426.62 humana medicare advantage ppo "inj octafluoropropane mic,ml" cpt Q9956 426.62 426.62 426.62 426.62 1209 1209 1007.5 1007.5 O 426.62 426.62 humana medicare advantage hmo "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 2504.71 2504.71 humana medicare advantage hmo "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 2504.71 2504.71 humana medicare advantage pos "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 2504.71 2504.71 humana medicare advantage ppo "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 2504.71 2504.71 humana medicare advantage hmo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 586.65 586.65 humana medicare advantage hmo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 586.65 586.65 humana medicare advantage pos "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 586.65 586.65 humana medicare advantage ppo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 586.65 586.65 humana medicare advantage hmo "locm 200-299mg/ml iodine,1ml" cpt Q9966 14120.9 14120.9 8777.72 8777.72 75967.02 75967.02 63305.85 63305.85 E 8777.72 8777.72 humana medicare advantage hmo "locm 200-299mg/ml iodine,1ml" cpt Q9966 14120.9 14120.9 8777.72 8777.72 75967.02 75967.02 63305.85 63305.85 E 8777.72 8777.72 humana medicare advantage pos "locm 200-299mg/ml iodine,1ml" cpt Q9966 14120.9 14120.9 8777.72 8777.72 75967.02 75967.02 63305.85 63305.85 E 8777.72 8777.72 humana medicare advantage ppo "locm 200-299mg/ml iodine,1ml" cpt Q9966 14120.9 14120.9 8777.72 8777.72 75967.02 75967.02 63305.85 63305.85 E 8777.72 8777.72 humana medicare advantage hmo "locm 200-299mg/ml iodine,1ml" cpt Q9966 8777.72 8777.72 1362.44 1362.44 45290.62 45290.62 37742.18 37742.18 O 8777.72 8777.72 humana medicare advantage hmo "locm 200-299mg/ml iodine,1ml" cpt Q9966 8777.72 8777.72 1362.44 1362.44 45290.62 45290.62 37742.18 37742.18 O 8777.72 8777.72 humana medicare advantage pos "locm 200-299mg/ml iodine,1ml" cpt Q9966 8777.72 8777.72 1362.44 1362.44 45290.62 45290.62 37742.18 37742.18 O 8777.72 8777.72 humana medicare advantage ppo "locm 200-299mg/ml iodine,1ml" cpt Q9966 8777.72 8777.72 1362.44 1362.44 45290.62 45290.62 37742.18 37742.18 O 8777.72 8777.72 humana medicare advantage hmo visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 4639.61 4639.61 humana medicare advantage hmo visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 4639.61 4639.61 humana medicare advantage pos visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 4639.61 4639.61 humana medicare advantage ppo visualization adjunct cpt Q9968 4639.61 4639.61 3661.72 3661.72 30332.77 30332.77 25277.31 25277.31 O 4639.61 4639.61 humana medicare advantage hmo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1130.05 1130.05 humana medicare advantage hmo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1130.05 1130.05 humana medicare advantage pos non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1130.05 1130.05 humana medicare advantage ppo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1130.05 1130.05 humana medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 68.95 68.95 humana medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 68.95 68.95 humana medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 68.95 68.95 humana medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 68.95 68.95 humana medicare advantage hmo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 4425.86 4425.86 humana medicare advantage hmo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 4425.86 4425.86 humana medicare advantage pos "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 4425.86 4425.86 humana medicare advantage ppo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 4425.86 4425.86 humana medicare advantage hmo contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 1791.13 1791.13 humana medicare advantage hmo contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 1791.13 1791.13 humana medicare advantage pos contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 1791.13 1791.13 humana medicare advantage ppo contact lens/es other type cpt V2599 4337.53 4337.53 1791.13 1791.13 19639.43 19639.43 16366.19 16366.19 O 1791.13 1791.13 humana medicare advantage hmo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 1791.13 1791.13 humana medicare advantage hmo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 1791.13 1791.13 humana medicare advantage pos post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 1791.13 1791.13 humana medicare advantage ppo post chmbr intraocular lens cpt V2632 7851.31 7851.31 1639 1639 14828.47 14828.47 12357.06 12357.06 O 1791.13 1791.13 humana medicare advantage hmo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1193.07 1193.07 humana medicare advantage hmo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1193.07 1193.07 humana medicare advantage pos General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1193.07 1193.07 humana medicare advantage ppo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 1193.07 1193.07 humana medicare advantage hmo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1259.33 1259.33 humana medicare advantage hmo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1259.33 1259.33 humana medicare advantage pos General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1259.33 1259.33 humana medicare advantage ppo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 1259.33 1259.33 humana medicare advantage hmo IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3259.12 3259.12 humana medicare advantage hmo IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3259.12 3259.12 humana medicare advantage pos IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3259.12 3259.12 humana medicare advantage ppo IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3259.12 3259.12 humana medicare advantage hmo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 2300.69 2300.69 humana medicare advantage hmo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 2300.69 2300.69 humana medicare advantage pos IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 2300.69 2300.69 humana medicare advantage ppo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 2300.69 2300.69 humana medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 humana medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 humana medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 humana medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 humana medicare advantage hmo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 1457.29 1457.29 humana medicare advantage hmo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 1457.29 1457.29 humana medicare advantage pos General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 1457.29 1457.29 humana medicare advantage ppo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 1457.29 1457.29 humana medicare advantage hmo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 408.55 408.55 humana medicare advantage hmo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 408.55 408.55 humana medicare advantage pos General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 408.55 408.55 humana medicare advantage ppo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 408.55 408.55 humana medicare advantage hmo "Insertion of catheter into abdominal pelvic or leg artery, each first order branch" cpt 36245 2455.02 2455.02 125.31 125.31 25382.86 25382.86 21152.38 21152.38 O 2455.02 2455.02 humana medicare advantage hmo "Insertion of catheter into abdominal pelvic or leg artery, each first order branch" cpt 36245 2455.02 2455.02 125.31 125.31 25382.86 25382.86 21152.38 21152.38 O 2455.02 2455.02 humana medicare advantage pos "Insertion of catheter into abdominal pelvic or leg artery, each first order branch" cpt 36245 2455.02 2455.02 125.31 125.31 25382.86 25382.86 21152.38 21152.38 O 2455.02 2455.02 humana medicare advantage ppo "Insertion of catheter into abdominal pelvic or leg artery, each first order branch" cpt 36245 2455.02 2455.02 125.31 125.31 25382.86 25382.86 21152.38 21152.38 O 2455.02 2455.02 humana medicare advantage hmo Repair of blood vessel of leg cpt 35226 653.76 653.76 653.76 653.76 1443.6 1443.6 1203 1203 E 653.76 653.76 humana medicare advantage hmo Repair of blood vessel of leg cpt 35226 653.76 653.76 653.76 653.76 1443.6 1443.6 1203 1203 E 653.76 653.76 humana medicare advantage pos Repair of blood vessel of leg cpt 35226 653.76 653.76 653.76 653.76 1443.6 1443.6 1203 1203 E 653.76 653.76 humana medicare advantage ppo Repair of blood vessel of leg cpt 35226 653.76 653.76 653.76 653.76 1443.6 1443.6 1203 1203 E 653.76 653.76 humana medicare advantage hmo Insertion or replacement of single or dual chamber pacing defibrillator leads cpt 33249 28598.55 28598.55 26166.91 26166.91 111127.04 111127.04 92605.87 92605.87 O 28598.55 28598.55 humana medicare advantage hmo Insertion or replacement of single or dual chamber pacing defibrillator leads cpt 33249 28598.55 28598.55 26166.91 26166.91 111127.04 111127.04 92605.87 92605.87 O 28598.55 28598.55 humana medicare advantage pos Insertion or replacement of single or dual chamber pacing defibrillator leads cpt 33249 28598.55 28598.55 26166.91 26166.91 111127.04 111127.04 92605.87 92605.87 O 28598.55 28598.55 humana medicare advantage ppo Insertion or replacement of single or dual chamber pacing defibrillator leads cpt 33249 28598.55 28598.55 26166.91 26166.91 111127.04 111127.04 92605.87 92605.87 O 28598.55 28598.55 humana medicare advantage hmo Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 4282.09 4282.09 humana medicare advantage hmo Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 4282.09 4282.09 humana medicare advantage pos Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 4282.09 4282.09 humana medicare advantage ppo Sterile revCode 272 14120.9 14120.9 4282.09 4282.09 56647.38 56647.38 47206.15 47206.15 O 4282.09 4282.09 humana medicare advantage hmo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 10573.89 10573.89 humana medicare advantage hmo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 10573.89 10573.89 humana medicare advantage pos Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 10573.89 10573.89 humana medicare advantage ppo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 10573.89 10573.89 humana medicare advantage hmo Removal and replacement of single lead permanent pacemaker pulse generator cpt 33227 6769.76 6769.76 6769.76 6769.76 28995.43 28995.43 24162.86 24162.86 O 6769.76 6769.76 humana medicare advantage hmo Removal and replacement of single lead permanent pacemaker pulse generator cpt 33227 6769.76 6769.76 6769.76 6769.76 28995.43 28995.43 24162.86 24162.86 O 6769.76 6769.76 humana medicare advantage pos Removal and replacement of single lead permanent pacemaker pulse generator cpt 33227 6769.76 6769.76 6769.76 6769.76 28995.43 28995.43 24162.86 24162.86 O 6769.76 6769.76 humana medicare advantage ppo Removal and replacement of single lead permanent pacemaker pulse generator cpt 33227 6769.76 6769.76 6769.76 6769.76 28995.43 28995.43 24162.86 24162.86 O 6769.76 6769.76 humana medicare advantage hmo "Insertion of needle into vein, patient 3 years or older" cpt 36410 1952.13 1952.13 750.1 750.1 17715.2 17715.2 14762.67 14762.67 E 1952.13 1952.13 humana medicare advantage hmo "Insertion of needle into vein, patient 3 years or older" cpt 36410 1952.13 1952.13 750.1 750.1 17715.2 17715.2 14762.67 14762.67 E 1952.13 1952.13 humana medicare advantage pos "Insertion of needle into vein, patient 3 years or older" cpt 36410 1952.13 1952.13 750.1 750.1 17715.2 17715.2 14762.67 14762.67 E 1952.13 1952.13 humana medicare advantage ppo "Insertion of needle into vein, patient 3 years or older" cpt 36410 1952.13 1952.13 750.1 750.1 17715.2 17715.2 14762.67 14762.67 E 1952.13 1952.13 humana medicare advantage hmo "Placement of temporary pacemaker leads, single chamber" cpt 33210 6636.16 6636.16 6636.16 6636.16 23055.73 23055.73 19213.11 19213.11 O 6636.16 6636.16 humana medicare advantage hmo "Placement of temporary pacemaker leads, single chamber" cpt 33210 6636.16 6636.16 6636.16 6636.16 23055.73 23055.73 19213.11 19213.11 O 6636.16 6636.16 humana medicare advantage pos "Placement of temporary pacemaker leads, single chamber" cpt 33210 6636.16 6636.16 6636.16 6636.16 23055.73 23055.73 19213.11 19213.11 O 6636.16 6636.16 humana medicare advantage ppo "Placement of temporary pacemaker leads, single chamber" cpt 33210 6636.16 6636.16 6636.16 6636.16 23055.73 23055.73 19213.11 19213.11 O 6636.16 6636.16 humana medicare advantage hmo Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 9081.99 9081.99 40085.34 40085.34 33404.45 33404.45 O 9081.99 9081.99 humana medicare advantage hmo Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 9081.99 9081.99 40085.34 40085.34 33404.45 33404.45 O 9081.99 9081.99 humana medicare advantage pos Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 9081.99 9081.99 40085.34 40085.34 33404.45 33404.45 O 9081.99 9081.99 humana medicare advantage ppo Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 9081.99 9081.99 40085.34 40085.34 33404.45 33404.45 O 9081.99 9081.99 humana medicare advantage hmo Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage pos Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage ppo Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes cpt 33208 9081.99 9081.99 8959.3 8959.3 52117.37 52117.37 43431.14 43431.14 E 8959.3 8959.3 humana medicare advantage hmo "Needle biopsy of lung or chest tissue, accessed through the skin" cpt 32405 1461.55 1461.55 1196.5 1196.5 10267.81 10267.81 8556.51 8556.51 O 1215.96 1215.96 humana medicare advantage hmo "Needle biopsy of lung or chest tissue, accessed through the skin" cpt 32405 1461.55 1461.55 1196.5 1196.5 10267.81 10267.81 8556.51 8556.51 O 1215.96 1215.96 humana medicare advantage pos "Needle biopsy of lung or chest tissue, accessed through the skin" cpt 32405 1461.55 1461.55 1196.5 1196.5 10267.81 10267.81 8556.51 8556.51 O 1215.96 1215.96 humana medicare advantage ppo "Needle biopsy of lung or chest tissue, accessed through the skin" cpt 32405 1461.55 1461.55 1196.5 1196.5 10267.81 10267.81 8556.51 8556.51 O 1215.96 1215.96 humana medicare advantage hmo Insertion of catheter for suction of secretions cpt 31720 2039.21 2039.21 194.68 194.68 1083.48 1083.48 902.9 902.9 E 2039.21 2039.21 humana medicare advantage hmo Insertion of catheter for suction of secretions cpt 31720 2039.21 2039.21 194.68 194.68 1083.48 1083.48 902.9 902.9 E 2039.21 2039.21 humana medicare advantage pos Insertion of catheter for suction of secretions cpt 31720 2039.21 2039.21 194.68 194.68 1083.48 1083.48 902.9 902.9 E 2039.21 2039.21 humana medicare advantage ppo Insertion of catheter for suction of secretions cpt 31720 2039.21 2039.21 194.68 194.68 1083.48 1083.48 902.9 902.9 E 2039.21 2039.21 humana medicare advantage hmo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11527.74 11527.74 humana medicare advantage hmo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11527.74 11527.74 humana medicare advantage pos intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11527.74 11527.74 humana medicare advantage ppo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11527.74 11527.74 humana medicare advantage hmo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1466.26 1466.26 humana medicare advantage hmo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1466.26 1466.26 humana medicare advantage pos Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1466.26 1466.26 humana medicare advantage ppo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 1466.26 1466.26 1066.8 1066.8 11133.48 11133.48 9277.9 9277.9 O 1466.26 1466.26 humana medicare advantage hmo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 23354.3 23354.3 humana medicare advantage hmo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 23354.3 23354.3 humana medicare advantage pos Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 23354.3 23354.3 humana medicare advantage ppo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 23354.3 23354.3 humana medicare advantage hmo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 851.56 851.56 humana medicare advantage hmo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 851.56 851.56 humana medicare advantage pos Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 851.56 851.56 humana medicare advantage ppo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 851.56 851.56 humana medicare advantage hmo General revCode 370 3748.71 3748.71 2455.02 2455.02 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage hmo General revCode 370 3748.71 3748.71 2455.02 2455.02 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage pos General revCode 370 3748.71 3748.71 2455.02 2455.02 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage ppo General revCode 370 3748.71 3748.71 2455.02 2455.02 36618.94 36618.94 30515.78 30515.78 E 3748.71 3748.71 humana medicare advantage hmo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 2076.66 2076.66 humana medicare advantage hmo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 2076.66 2076.66 humana medicare advantage pos General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 2076.66 2076.66 humana medicare advantage ppo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 2076.66 2076.66 humana medicare advantage hmo Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 1328.48 1328.48 humana medicare advantage hmo Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 1328.48 1328.48 humana medicare advantage pos Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 1328.48 1328.48 humana medicare advantage ppo Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 1328.48 1328.48 humana medicare advantage hmo Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 2425.05 2425.05 humana medicare advantage hmo Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 2425.05 2425.05 humana medicare advantage pos Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 2425.05 2425.05 humana medicare advantage ppo Repair of shoulder rotator cuff using an endoscope cpt 29827 15196.01 15196.01 2425.05 2425.05 38203.72 38203.72 31836.43 31836.43 O 2425.05 2425.05 humana medicare advantage hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6299.79 6299.79 humana medicare advantage hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6299.79 6299.79 humana medicare advantage pos intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6299.79 6299.79 humana medicare advantage ppo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6299.79 6299.79 humana medicare advantage hmo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 2425.05 2425.05 humana medicare advantage hmo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 2425.05 2425.05 humana medicare advantage pos Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 2425.05 2425.05 humana medicare advantage ppo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 2425.05 2425.05 humana medicare advantage hmo Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 2425.05 2425.05 humana medicare advantage hmo Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 2425.05 2425.05 humana medicare advantage pos Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 2425.05 2425.05 humana medicare advantage ppo Removal of shoulder joint tissue using an endoscope cpt 29822 5550.48 5550.48 2386.25 2386.25 27571.72 27571.72 22976.43 22976.43 O 2425.05 2425.05 humana medicare advantage hmo General revCode 710 3748.71 3748.71 2435.38 2435.38 30308.78 30308.78 25257.32 25257.32 E 3748.71 3748.71 humana medicare advantage hmo General revCode 710 3748.71 3748.71 2435.38 2435.38 30308.78 30308.78 25257.32 25257.32 E 3748.71 3748.71 humana medicare advantage pos General revCode 710 3748.71 3748.71 2435.38 2435.38 30308.78 30308.78 25257.32 25257.32 E 3748.71 3748.71 humana medicare advantage ppo General revCode 710 3748.71 3748.71 2435.38 2435.38 30308.78 30308.78 25257.32 25257.32 E 3748.71 3748.71 humana medicare advantage hmo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 2524.71 2524.71 humana medicare advantage hmo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 2524.71 2524.71 humana medicare advantage pos General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 2524.71 2524.71 humana medicare advantage ppo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 2524.71 2524.71 humana medicare advantage hmo Amputation of toe at joint between the forefoot and toes cpt 28820 2386.25 2386.25 2298.06 2298.06 16258 16258 13548.33 13548.33 O 2382.45 2382.45 humana medicare advantage hmo Amputation of toe at joint between the forefoot and toes cpt 28820 2386.25 2386.25 2298.06 2298.06 16258 16258 13548.33 13548.33 O 2382.45 2382.45 humana medicare advantage pos Amputation of toe at joint between the forefoot and toes cpt 28820 2386.25 2386.25 2298.06 2298.06 16258 16258 13548.33 13548.33 O 2382.45 2382.45 humana medicare advantage ppo Amputation of toe at joint between the forefoot and toes cpt 28820 2386.25 2386.25 2298.06 2298.06 16258 16258 13548.33 13548.33 O 2382.45 2382.45 humana medicare advantage hmo Amputation of toe and midfoot bone cpt 28810 2425.05 2425.05 2386.25 2386.25 18552.49 18552.49 15460.41 15460.41 O 2425.05 2425.05 humana medicare advantage hmo Amputation of toe and midfoot bone cpt 28810 2425.05 2425.05 2386.25 2386.25 18552.49 18552.49 15460.41 15460.41 O 2425.05 2425.05 humana medicare advantage pos Amputation of toe and midfoot bone cpt 28810 2425.05 2425.05 2386.25 2386.25 18552.49 18552.49 15460.41 15460.41 O 2425.05 2425.05 humana medicare advantage ppo Amputation of toe and midfoot bone cpt 28810 2425.05 2425.05 2386.25 2386.25 18552.49 18552.49 15460.41 15460.41 O 2425.05 2425.05 humana medicare advantage hmo Treatment room revCode 761 1193.07 1193.07 1193.07 1193.07 14428.14 14428.14 12023.45 12023.45 E 1193.07 1193.07 humana medicare advantage hmo Treatment room revCode 761 1193.07 1193.07 1193.07 1193.07 14428.14 14428.14 12023.45 12023.45 E 1193.07 1193.07 humana medicare advantage pos Treatment room revCode 761 1193.07 1193.07 1193.07 1193.07 14428.14 14428.14 12023.45 12023.45 E 1193.07 1193.07 humana medicare advantage ppo Treatment room revCode 761 1193.07 1193.07 1193.07 1193.07 14428.14 14428.14 12023.45 12023.45 E 1193.07 1193.07 humana medicare advantage hmo "Correction of bunion, with alignment correction of midfoot bone (metatarsal) towards toe areas" cpt 28296 5299.29 5299.29 2425.05 2425.05 21810.48 21810.48 18175.4 18175.4 O 2425.05 2425.05 humana medicare advantage hmo "Correction of bunion, with alignment correction of midfoot bone (metatarsal) towards toe areas" cpt 28296 5299.29 5299.29 2425.05 2425.05 21810.48 21810.48 18175.4 18175.4 O 2425.05 2425.05 humana medicare advantage pos "Correction of bunion, with alignment correction of midfoot bone (metatarsal) towards toe areas" cpt 28296 5299.29 5299.29 2425.05 2425.05 21810.48 21810.48 18175.4 18175.4 O 2425.05 2425.05 humana medicare advantage ppo "Correction of bunion, with alignment correction of midfoot bone (metatarsal) towards toe areas" cpt 28296 5299.29 5299.29 2425.05 2425.05 21810.48 21810.48 18175.4 18175.4 O 2425.05 2425.05 humana medicare advantage hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1952.13 1952.13 humana medicare advantage hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1952.13 1952.13 humana medicare advantage pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1952.13 1952.13 humana medicare advantage ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1952.13 1952.13 humana medicare advantage hmo "Incision to lengthen toe tendon, open procedure" cpt 28232 2383.1 2383.1 2383.1 2383.1 19047.34 19047.34 15872.78 15872.78 O 2383.1 2383.1 humana medicare advantage hmo "Incision to lengthen toe tendon, open procedure" cpt 28232 2383.1 2383.1 2383.1 2383.1 19047.34 19047.34 15872.78 15872.78 O 2383.1 2383.1 humana medicare advantage pos "Incision to lengthen toe tendon, open procedure" cpt 28232 2383.1 2383.1 2383.1 2383.1 19047.34 19047.34 15872.78 15872.78 O 2383.1 2383.1 humana medicare advantage ppo "Incision to lengthen toe tendon, open procedure" cpt 28232 2383.1 2383.1 2383.1 2383.1 19047.34 19047.34 15872.78 15872.78 O 2383.1 2383.1 humana medicare advantage hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 1503.55 1503.55 humana medicare advantage hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 1503.55 1503.55 humana medicare advantage pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 1503.55 1503.55 humana medicare advantage ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 1503.55 1503.55 humana medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 humana medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 humana medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 humana medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 1952.13 1952.13 humana medicare advantage hmo Partial removal of toe bone cpt 28124 2383.75 2383.75 2248.64 2248.64 19187.63 19187.63 15989.69 15989.69 O 2383.75 2383.75 humana medicare advantage hmo Partial removal of toe bone cpt 28124 2383.75 2383.75 2248.64 2248.64 19187.63 19187.63 15989.69 15989.69 O 2383.75 2383.75 humana medicare advantage pos Partial removal of toe bone cpt 28124 2383.75 2383.75 2248.64 2248.64 19187.63 19187.63 15989.69 15989.69 O 2383.75 2383.75 humana medicare advantage ppo Partial removal of toe bone cpt 28124 2383.75 2383.75 2248.64 2248.64 19187.63 19187.63 15989.69 15989.69 O 2383.75 2383.75 humana medicare advantage hmo Partial removal of foot or heel bone for bone infection in the midfoot area cpt 28122 2425.05 2425.05 2425.05 2425.05 22013.7 22013.7 18344.75 18344.75 O 2425.05 2425.05 humana medicare advantage hmo Partial removal of foot or heel bone for bone infection in the midfoot area cpt 28122 2425.05 2425.05 2425.05 2425.05 22013.7 22013.7 18344.75 18344.75 O 2425.05 2425.05 humana medicare advantage pos Partial removal of foot or heel bone for bone infection in the midfoot area cpt 28122 2425.05 2425.05 2425.05 2425.05 22013.7 22013.7 18344.75 18344.75 O 2425.05 2425.05 humana medicare advantage ppo Partial removal of foot or heel bone for bone infection in the midfoot area cpt 28122 2425.05 2425.05 2425.05 2425.05 22013.7 22013.7 18344.75 18344.75 O 2425.05 2425.05 humana medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 humana medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 humana medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 humana medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 humana medicare advantage hmo Removal of heel bone cpt 28118 5299.29 5299.29 5299.29 5299.29 37086.2 37086.2 30905.17 30905.17 O 5299.29 5299.29 humana medicare advantage hmo Removal of heel bone cpt 28118 5299.29 5299.29 5299.29 5299.29 37086.2 37086.2 30905.17 30905.17 O 5299.29 5299.29 humana medicare advantage pos Removal of heel bone cpt 28118 5299.29 5299.29 5299.29 5299.29 37086.2 37086.2 30905.17 30905.17 O 5299.29 5299.29 humana medicare advantage ppo Removal of heel bone cpt 28118 5299.29 5299.29 5299.29 5299.29 37086.2 37086.2 30905.17 30905.17 O 5299.29 5299.29 humana medicare advantage hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 11643.48 11643.48 humana medicare advantage hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 11643.48 11643.48 humana medicare advantage pos Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 11643.48 11643.48 humana medicare advantage ppo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 11643.48 11643.48 humana medicare advantage hmo Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 13282.95 13282.95 humana medicare advantage hmo Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 13282.95 13282.95 humana medicare advantage pos Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 13282.95 13282.95 humana medicare advantage ppo Cervical spinal fusion ms-drg 473 18636.78 18636.78 12339.04 12339.04 71424.26 71424.26 59520.22 59520.22 I 13282.95 13282.95 humana medicare advantage hmo Open treatment of all three prominences of the bones of the leg (tibia and fibula) in the region of the ankle cpt 27822 5299.29 5299.29 5199.2 5199.2 42880.74 42880.74 35733.95 35733.95 O 5199.2 5199.2 humana medicare advantage hmo Open treatment of all three prominences of the bones of the leg (tibia and fibula) in the region of the ankle cpt 27822 5299.29 5299.29 5199.2 5199.2 42880.74 42880.74 35733.95 35733.95 O 5199.2 5199.2 humana medicare advantage pos Open treatment of all three prominences of the bones of the leg (tibia and fibula) in the region of the ankle cpt 27822 5299.29 5299.29 5199.2 5199.2 42880.74 42880.74 35733.95 35733.95 O 5199.2 5199.2 humana medicare advantage ppo Open treatment of all three prominences of the bones of the leg (tibia and fibula) in the region of the ankle cpt 27822 5299.29 5299.29 5199.2 5199.2 42880.74 42880.74 35733.95 35733.95 O 5199.2 5199.2 humana medicare advantage hmo Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1191.11 1191.11 1178.5 1178.5 4865.9 4865.9 4054.92 4054.92 E 1178.5 1178.5 humana medicare advantage hmo Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1191.11 1191.11 1178.5 1178.5 4865.9 4865.9 4054.92 4054.92 E 1178.5 1178.5 humana medicare advantage pos Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1191.11 1191.11 1178.5 1178.5 4865.9 4865.9 4054.92 4054.92 E 1178.5 1178.5 humana medicare advantage ppo Closed treatment of all three the portions of the bones of the leg (tibia and fibula) in the region of the ankle with manipulation cpt 27818 1191.11 1191.11 1178.5 1178.5 4865.9 4865.9 4054.92 4054.92 E 1178.5 1178.5 humana medicare advantage hmo Open treatment of prominences of both bones of the leg (tibia and fibula) in the region of the ankle without hardware fixation cpt 27814 5299.29 5299.29 5299.29 5299.29 35942.2 35942.2 29951.83 29951.83 O 5299.29 5299.29 humana medicare advantage hmo Open treatment of prominences of both bones of the leg (tibia and fibula) in the region of the ankle without hardware fixation cpt 27814 5299.29 5299.29 5299.29 5299.29 35942.2 35942.2 29951.83 29951.83 O 5299.29 5299.29 humana medicare advantage pos Open treatment of prominences of both bones of the leg (tibia and fibula) in the region of the ankle without hardware fixation cpt 27814 5299.29 5299.29 5299.29 5299.29 35942.2 35942.2 29951.83 29951.83 O 5299.29 5299.29 humana medicare advantage ppo Open treatment of prominences of both bones of the leg (tibia and fibula) in the region of the ankle without hardware fixation cpt 27814 5299.29 5299.29 5299.29 5299.29 35942.2 35942.2 29951.83 29951.83 O 5299.29 5299.29 humana medicare advantage hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4626.86 4626.86 humana medicare advantage hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4626.86 4626.86 humana medicare advantage pos Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4626.86 4626.86 humana medicare advantage ppo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 4626.86 4626.86 humana medicare advantage hmo major chest procedures with mcc ms-drg 163 28721.37 28721.37 15759.84 15759.84 142219.09 142219.09 118515.91 118515.91 I 26509.5 26509.5 humana medicare advantage hmo major chest procedures with mcc ms-drg 163 28721.37 28721.37 15759.84 15759.84 142219.09 142219.09 118515.91 118515.91 I 26509.5 26509.5 humana medicare advantage pos major chest procedures with mcc ms-drg 163 28721.37 28721.37 15759.84 15759.84 142219.09 142219.09 118515.91 118515.91 I 26509.5 26509.5 humana medicare advantage ppo major chest procedures with mcc ms-drg 163 28721.37 28721.37 15759.84 15759.84 142219.09 142219.09 118515.91 118515.91 I 26509.5 26509.5 humana medicare advantage hmo major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 15185.68 15185.68 humana medicare advantage hmo major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 15185.68 15185.68 humana medicare advantage pos major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 15185.68 15185.68 humana medicare advantage ppo major chest procedures with cc ms-drg 164 25248.79 25248.79 14423.44 14423.44 88686.06 88686.06 73905.05 73905.05 I 15185.68 15185.68 humana medicare advantage hmo major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 11400.92 11400.92 humana medicare advantage hmo major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 11400.92 11400.92 humana medicare advantage pos major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 11400.92 11400.92 humana medicare advantage ppo major chest procedures without cc/mcc ms-drg 165 22244.9 22244.9 8174.76 8174.76 84098.41 84098.41 70082.01 70082.01 I 11400.92 11400.92 humana medicare advantage hmo Removal of ankle implant cpt 27704 581.83 581.83 581.83 581.83 28247.05 28247.05 23539.21 23539.21 O 581.83 581.83 humana medicare advantage hmo Removal of ankle implant cpt 27704 581.83 581.83 581.83 581.83 28247.05 28247.05 23539.21 23539.21 O 581.83 581.83 humana medicare advantage pos Removal of ankle implant cpt 27704 581.83 581.83 581.83 581.83 28247.05 28247.05 23539.21 23539.21 O 581.83 581.83 humana medicare advantage ppo Removal of ankle implant cpt 27704 581.83 581.83 581.83 581.83 28247.05 28247.05 23539.21 23539.21 O 581.83 581.83 humana medicare advantage hmo Lengthening of calf muscle cpt 27687 3544.14 3544.14 2425.05 2425.05 29642.78 29642.78 24702.32 24702.32 O 2425.05 2425.05 humana medicare advantage hmo Lengthening of calf muscle cpt 27687 3544.14 3544.14 2425.05 2425.05 29642.78 29642.78 24702.32 24702.32 O 2425.05 2425.05 humana medicare advantage pos Lengthening of calf muscle cpt 27687 3544.14 3544.14 2425.05 2425.05 29642.78 29642.78 24702.32 24702.32 O 2425.05 2425.05 humana medicare advantage ppo Lengthening of calf muscle cpt 27687 3544.14 3544.14 2425.05 2425.05 29642.78 29642.78 24702.32 24702.32 O 2425.05 2425.05 humana medicare advantage hmo "Repair of ruptured Achilles tendon, open or through skin procedure" cpt 27650 5299.29 5299.29 5299.29 5299.29 38357.64 38357.64 31964.7 31964.7 O 5299.29 5299.29 humana medicare advantage hmo "Repair of ruptured Achilles tendon, open or through skin procedure" cpt 27650 5299.29 5299.29 5299.29 5299.29 38357.64 38357.64 31964.7 31964.7 O 5299.29 5299.29 humana medicare advantage pos "Repair of ruptured Achilles tendon, open or through skin procedure" cpt 27650 5299.29 5299.29 5299.29 5299.29 38357.64 38357.64 31964.7 31964.7 O 5299.29 5299.29 humana medicare advantage ppo "Repair of ruptured Achilles tendon, open or through skin procedure" cpt 27650 5299.29 5299.29 5299.29 5299.29 38357.64 38357.64 31964.7 31964.7 O 5299.29 5299.29 humana medicare advantage hmo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 11621.07 11621.07 humana medicare advantage hmo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 11621.07 11621.07 humana medicare advantage pos respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 11621.07 11621.07 humana medicare advantage ppo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 11621.07 11621.07 humana medicare advantage hmo Alignment of knee joint under anesthesia cpt 27570 1200.71 1200.71 1138.71 1138.71 12245.21 12245.21 10204.34 10204.34 O 1200.71 1200.71 humana medicare advantage hmo Alignment of knee joint under anesthesia cpt 27570 1200.71 1200.71 1138.71 1138.71 12245.21 12245.21 10204.34 10204.34 O 1200.71 1200.71 humana medicare advantage pos Alignment of knee joint under anesthesia cpt 27570 1200.71 1200.71 1138.71 1138.71 12245.21 12245.21 10204.34 10204.34 O 1200.71 1200.71 humana medicare advantage ppo Alignment of knee joint under anesthesia cpt 27570 1200.71 1200.71 1138.71 1138.71 12245.21 12245.21 10204.34 10204.34 O 1200.71 1200.71 humana medicare advantage hmo pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 8004.74 8004.74 humana medicare advantage hmo pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 8004.74 8004.74 humana medicare advantage pos pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 8004.74 8004.74 humana medicare advantage ppo pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 8004.74 8004.74 humana medicare advantage hmo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 6073.51 6073.51 humana medicare advantage hmo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 6073.51 6073.51 humana medicare advantage pos simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 6073.51 6073.51 humana medicare advantage ppo simple pneumonia and pleurisy with cc ms-drg 194 9778.82 9778.82 3554.32 3554.32 20194.99 20194.99 16829.16 16829.16 I 6073.51 6073.51 humana medicare advantage hmo simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 4917.44 4917.44 humana medicare advantage hmo simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 4917.44 4917.44 humana medicare advantage pos simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 4917.44 4917.44 humana medicare advantage ppo simple pneumonia and pleurisy without cc/mcc ms-drg 195 8418.87 8418.87 2370.55 2370.55 17403.08 17403.08 14502.57 14502.57 I 4917.44 4917.44 humana medicare advantage hmo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 1200.71 1200.71 humana medicare advantage hmo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 1200.71 1200.71 humana medicare advantage pos Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 1200.71 1200.71 humana medicare advantage ppo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 1200.71 1200.71 humana medicare advantage hmo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 17256.44 17256.44 humana medicare advantage hmo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 17256.44 17256.44 humana medicare advantage pos respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 17256.44 17256.44 humana medicare advantage ppo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 17256.44 17256.44 humana medicare advantage hmo respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 15147.62 15147.62 humana medicare advantage hmo respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 15147.62 15147.62 humana medicare advantage pos respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 15147.62 15147.62 humana medicare advantage ppo respiratory system diagnosis with ventilator support <=96 hours ms-drg 208 26637.75 26637.75 10337.94 10337.94 70235.36 70235.36 58529.47 58529.47 I 15147.62 15147.62 humana medicare advantage hmo other heart assist system implant ms-drg 215 75544.03 75544.03 73725.61 73725.61 218033.38 218033.38 181694.48 181694.48 I 73725.61 73725.61 humana medicare advantage hmo other heart assist system implant ms-drg 215 75544.03 75544.03 73725.61 73725.61 218033.38 218033.38 181694.48 181694.48 I 73725.61 73725.61 humana medicare advantage pos other heart assist system implant ms-drg 215 75544.03 75544.03 73725.61 73725.61 218033.38 218033.38 181694.48 181694.48 I 73725.61 73725.61 humana medicare advantage ppo other heart assist system implant ms-drg 215 75544.03 75544.03 73725.61 73725.61 218033.38 218033.38 181694.48 181694.48 I 73725.61 73725.61 humana medicare advantage hmo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 626.2 626.2 humana medicare advantage hmo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 626.2 626.2 humana medicare advantage pos cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 626.2 626.2 humana medicare advantage ppo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 626.2 626.2 humana medicare advantage hmo "Drainage of finger abscess, uncomplicated" cpt 26010 352.64 352.64 229.65 229.65 1309.74 1309.74 1091.45 1091.45 E 268.15 268.15 humana medicare advantage hmo "Drainage of finger abscess, uncomplicated" cpt 26010 352.64 352.64 229.65 229.65 1309.74 1309.74 1091.45 1091.45 E 268.15 268.15 humana medicare advantage pos "Drainage of finger abscess, uncomplicated" cpt 26010 352.64 352.64 229.65 229.65 1309.74 1309.74 1091.45 1091.45 E 268.15 268.15 humana medicare advantage ppo "Drainage of finger abscess, uncomplicated" cpt 26010 352.64 352.64 229.65 229.65 1309.74 1309.74 1091.45 1091.45 E 268.15 268.15 humana medicare advantage hmo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 28792.96 28792.96 humana medicare advantage hmo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 28792.96 28792.96 humana medicare advantage pos coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 28792.96 28792.96 humana medicare advantage ppo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 28792.96 28792.96 humana medicare advantage hmo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 23475.39 23475.39 humana medicare advantage hmo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 23475.39 23475.39 humana medicare advantage pos coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 23475.39 23475.39 humana medicare advantage ppo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 23475.39 23475.39 humana medicare advantage hmo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 19025.98 19025.98 humana medicare advantage hmo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 19025.98 19025.98 humana medicare advantage pos percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 19025.98 19025.98 humana medicare advantage ppo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 19025.98 19025.98 humana medicare advantage hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12067.36 12067.36 humana medicare advantage hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12067.36 12067.36 humana medicare advantage pos percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12067.36 12067.36 humana medicare advantage ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12067.36 12067.36 humana medicare advantage hmo percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 15245.66 15245.66 humana medicare advantage hmo percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 15245.66 15245.66 humana medicare advantage pos percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 15245.66 15245.66 humana medicare advantage ppo percutaneous cardiovascular procedures without coronary artery stent with mcc ms-drg 250 26746.13 26746.13 15245.66 15245.66 91705.07 91705.07 76420.89 76420.89 I 15245.66 15245.66 humana medicare advantage hmo other vascular procedures with mcc ms-drg 252 20085.02 20085.02 17890.5 17890.5 99426.43 99426.43 82855.36 82855.36 I 17890.5 17890.5 humana medicare advantage hmo other vascular procedures with mcc ms-drg 252 20085.02 20085.02 17890.5 17890.5 99426.43 99426.43 82855.36 82855.36 I 17890.5 17890.5 humana medicare advantage pos other vascular procedures with mcc ms-drg 252 20085.02 20085.02 17890.5 17890.5 99426.43 99426.43 82855.36 82855.36 I 17890.5 17890.5 humana medicare advantage ppo other vascular procedures with mcc ms-drg 252 20085.02 20085.02 17890.5 17890.5 99426.43 99426.43 82855.36 82855.36 I 17890.5 17890.5 humana medicare advantage hmo other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 15837.47 15837.47 humana medicare advantage hmo other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 15837.47 15837.47 humana medicare advantage pos other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 15837.47 15837.47 humana medicare advantage ppo other vascular procedures with cc ms-drg 253 29514.43 29514.43 14757.06 14757.06 79211.92 79211.92 66009.93 66009.93 I 15837.47 15837.47 humana medicare advantage hmo other vascular procedures without cc/mcc ms-drg 254 13485.52 13485.52 10936.61 10936.61 37141.75 37141.75 30951.46 30951.46 I 11408.37 11408.37 humana medicare advantage hmo other vascular procedures without cc/mcc ms-drg 254 13485.52 13485.52 10936.61 10936.61 37141.75 37141.75 30951.46 30951.46 I 11408.37 11408.37 humana medicare advantage pos other vascular procedures without cc/mcc ms-drg 254 13485.52 13485.52 10936.61 10936.61 37141.75 37141.75 30951.46 30951.46 I 11408.37 11408.37 humana medicare advantage ppo other vascular procedures without cc/mcc ms-drg 254 13485.52 13485.52 10936.61 10936.61 37141.75 37141.75 30951.46 30951.46 I 11408.37 11408.37 humana medicare advantage hmo aortic and heart assist procedures except pulsation balloon with mcc ms-drg 268 39553.36 39553.36 703.02 703.02 154446.77 154446.77 128705.64 128705.64 I 703.02 703.02 humana medicare advantage hmo aortic and heart assist procedures except pulsation balloon with mcc ms-drg 268 39553.36 39553.36 703.02 703.02 154446.77 154446.77 128705.64 128705.64 I 703.02 703.02 humana medicare advantage pos aortic and heart assist procedures except pulsation balloon with mcc ms-drg 268 39553.36 39553.36 703.02 703.02 154446.77 154446.77 128705.64 128705.64 I 703.02 703.02 humana medicare advantage ppo aortic and heart assist procedures except pulsation balloon with mcc ms-drg 268 39553.36 39553.36 703.02 703.02 154446.77 154446.77 128705.64 128705.64 I 703.02 703.02 humana medicare advantage hmo aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 12983.39 12983.39 humana medicare advantage hmo aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 12983.39 12983.39 humana medicare advantage pos aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 12983.39 12983.39 humana medicare advantage ppo aortic and heart assist procedures except pulsation balloon without mcc ms-drg 269 43254.05 43254.05 12983.39 12983.39 111818.45 111818.45 93182.04 93182.04 I 12983.39 12983.39 humana medicare advantage hmo other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 19105.86 19105.86 humana medicare advantage hmo other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 19105.86 19105.86 humana medicare advantage pos other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 19105.86 19105.86 humana medicare advantage ppo other major cardiovascular procedures with cc ms-drg 271 34817.44 34817.44 19105.86 19105.86 134179.22 134179.22 111816.02 111816.02 I 19105.86 19105.86 humana medicare advantage hmo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 13335.64 13335.64 humana medicare advantage hmo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 13335.64 13335.64 humana medicare advantage pos "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 13335.64 13335.64 humana medicare advantage ppo "circulatory disorders except ami, with cardiac catheterization with mcc" ms-drg 286 23670.85 23670.85 12375.58 12375.58 57221.47 57221.47 47684.56 47684.56 I 13335.64 13335.64 humana medicare advantage hmo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 941.39 941.39 humana medicare advantage hmo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 941.39 941.39 humana medicare advantage pos Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 941.39 941.39 humana medicare advantage ppo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 941.39 941.39 humana medicare advantage hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8423.14 8423.14 humana medicare advantage hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8423.14 8423.14 humana medicare advantage pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8423.14 8423.14 humana medicare advantage ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8423.14 8423.14 humana medicare advantage hmo cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7607.38 7607.38 humana medicare advantage hmo cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7607.38 7607.38 humana medicare advantage pos cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7607.38 7607.38 humana medicare advantage ppo cardiac arrhythmia and conduction disorders with mcc ms-drg 308 7858.02 7858.02 6156.23 6156.23 35585.35 35585.35 29654.46 29654.46 I 7607.38 7607.38 humana medicare advantage hmo "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 10573.89 10573.89 humana medicare advantage hmo "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 10573.89 10573.89 humana medicare advantage pos "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 10573.89 10573.89 humana medicare advantage ppo "Insertion of posterior spinal instrumentation at base of neck for stabilization, 1 interspace" cpt 22840 10625.2 10625.2 71.67 71.67 100078.81 100078.81 83399.01 83399.01 O 10573.89 10573.89 humana medicare advantage hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4910.45 4910.45 humana medicare advantage hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4910.45 4910.45 humana medicare advantage pos cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4910.45 4910.45 humana medicare advantage ppo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4910.45 4910.45 humana medicare advantage hmo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3881.13 3881.13 humana medicare advantage hmo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3881.13 3881.13 humana medicare advantage pos cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3881.13 3881.13 humana medicare advantage ppo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 3881.13 3881.13 humana medicare advantage hmo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5682.31 5682.31 humana medicare advantage hmo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5682.31 5682.31 humana medicare advantage pos syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5682.31 5682.31 humana medicare advantage ppo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5682.31 5682.31 humana medicare advantage hmo "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 10573.89 10573.89 humana medicare advantage hmo "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 10573.89 10573.89 humana medicare advantage pos "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 10573.89 10573.89 humana medicare advantage ppo "Fusion of spine bones, posterior or posterolateral approach" cpt 22614 10625.2 10625.2 6298.42 6298.42 107170.56 107170.56 89308.8 89308.8 O 10573.89 10573.89 humana medicare advantage hmo "Fusion of lower spine bones, posterior or posterolateral approach" cpt 22612 10625.2 10625.2 71.67 71.67 98531.21 98531.21 82109.34 82109.34 O 10573.89 10573.89 humana medicare advantage hmo "Fusion of lower spine bones, posterior or posterolateral approach" cpt 22612 10625.2 10625.2 71.67 71.67 98531.21 98531.21 82109.34 82109.34 O 10573.89 10573.89 humana medicare advantage pos "Fusion of lower spine bones, posterior or posterolateral approach" cpt 22612 10625.2 10625.2 71.67 71.67 98531.21 98531.21 82109.34 82109.34 O 10573.89 10573.89 humana medicare advantage ppo "Fusion of lower spine bones, posterior or posterolateral approach" cpt 22612 10625.2 10625.2 71.67 71.67 98531.21 98531.21 82109.34 82109.34 O 10573.89 10573.89 humana medicare advantage hmo major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 28508.13 28508.13 humana medicare advantage hmo major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 28508.13 28508.13 humana medicare advantage pos major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 28508.13 28508.13 humana medicare advantage ppo major small and large bowel procedures with mcc ms-drg 329 36464.38 36464.38 24057.11 24057.11 121868.66 121868.66 101557.22 101557.22 I 28508.13 28508.13 humana medicare advantage hmo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 14581.38 14581.38 humana medicare advantage hmo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 14581.38 14581.38 humana medicare advantage pos major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 14581.38 14581.38 humana medicare advantage ppo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 14581.38 14581.38 humana medicare advantage hmo Injection of bone cement into body of middle or lower spine bone accessed through the skin using imaging guidance cpt 22515 10542.6 10542.6 5180.14 5180.14 62407.9 62407.9 52006.58 52006.58 O 10542.6 10542.6 humana medicare advantage hmo Injection of bone cement into body of middle or lower spine bone accessed through the skin using imaging guidance cpt 22515 10542.6 10542.6 5180.14 5180.14 62407.9 62407.9 52006.58 52006.58 O 10542.6 10542.6 humana medicare advantage pos Injection of bone cement into body of middle or lower spine bone accessed through the skin using imaging guidance cpt 22515 10542.6 10542.6 5180.14 5180.14 62407.9 62407.9 52006.58 52006.58 O 10542.6 10542.6 humana medicare advantage ppo Injection of bone cement into body of middle or lower spine bone accessed through the skin using imaging guidance cpt 22515 10542.6 10542.6 5180.14 5180.14 62407.9 62407.9 52006.58 52006.58 O 10542.6 10542.6 humana medicare advantage hmo major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 10550.05 10550.05 humana medicare advantage hmo major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 10550.05 10550.05 humana medicare advantage pos major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 10550.05 10550.05 humana medicare advantage ppo major small and large bowel procedures without cc/mcc ms-drg 331 11874.88 11874.88 7725.86 7725.86 56955.92 56955.92 47463.27 47463.27 I 10550.05 10550.05 humana medicare advantage hmo Injection of bone cement into body of lower spine bone accessed through the skin using imaging guidance cpt 22514 5299.29 5299.29 0.36 0.36 37771.36 37771.36 31476.13 31476.13 O 5093.22 5093.22 humana medicare advantage hmo Injection of bone cement into body of lower spine bone accessed through the skin using imaging guidance cpt 22514 5299.29 5299.29 0.36 0.36 37771.36 37771.36 31476.13 31476.13 O 5093.22 5093.22 humana medicare advantage pos Injection of bone cement into body of lower spine bone accessed through the skin using imaging guidance cpt 22514 5299.29 5299.29 0.36 0.36 37771.36 37771.36 31476.13 31476.13 O 5093.22 5093.22 humana medicare advantage ppo Injection of bone cement into body of lower spine bone accessed through the skin using imaging guidance cpt 22514 5299.29 5299.29 0.36 0.36 37771.36 37771.36 31476.13 31476.13 O 5093.22 5093.22 humana medicare advantage hmo Injection of bone cement into body of middle spine bone accessed through the skin using imaging guidance in the thoracic to correct forward bending cpt 22513 10542.6 10542.6 5256.9 5256.9 32081.46 32081.46 26734.55 26734.55 O 10542.6 10542.6 humana medicare advantage hmo Injection of bone cement into body of middle spine bone accessed through the skin using imaging guidance in the thoracic to correct forward bending cpt 22513 10542.6 10542.6 5256.9 5256.9 32081.46 32081.46 26734.55 26734.55 O 10542.6 10542.6 humana medicare advantage pos Injection of bone cement into body of middle spine bone accessed through the skin using imaging guidance in the thoracic to correct forward bending cpt 22513 10542.6 10542.6 5256.9 5256.9 32081.46 32081.46 26734.55 26734.55 O 10542.6 10542.6 humana medicare advantage ppo Injection of bone cement into body of middle spine bone accessed through the skin using imaging guidance in the thoracic to correct forward bending cpt 22513 10542.6 10542.6 5256.9 5256.9 32081.46 32081.46 26734.55 26734.55 O 10542.6 10542.6 humana medicare advantage hmo Harvest of bone from same spine incision for graft cpt 20936 10573.89 10573.89 10359.91 10359.91 90858.1 90858.1 75715.08 75715.08 O 10573.89 10573.89 humana medicare advantage hmo Harvest of bone from same spine incision for graft cpt 20936 10573.89 10573.89 10359.91 10359.91 90858.1 90858.1 75715.08 75715.08 O 10573.89 10573.89 humana medicare advantage pos Harvest of bone from same spine incision for graft cpt 20936 10573.89 10573.89 10359.91 10359.91 90858.1 90858.1 75715.08 75715.08 O 10573.89 10573.89 humana medicare advantage ppo Harvest of bone from same spine incision for graft cpt 20936 10573.89 10573.89 10359.91 10359.91 90858.1 90858.1 75715.08 75715.08 O 10573.89 10573.89 humana medicare advantage hmo hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 10856.49 10856.49 humana medicare advantage hmo hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 10856.49 10856.49 humana medicare advantage pos hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 10856.49 10856.49 humana medicare advantage ppo hernia procedures except inguinal and femoral with cc ms-drg 354 19392.75 19392.75 10856.49 10856.49 65200.49 65200.49 54333.74 54333.74 I 10856.49 10856.49 humana medicare advantage hmo major esophageal disorders with mcc ms-drg 368 12011.24 12011.24 11493.96 11493.96 41590.37 41590.37 34658.64 34658.64 I 11887.75 11887.75 humana medicare advantage hmo major esophageal disorders with mcc ms-drg 368 12011.24 12011.24 11493.96 11493.96 41590.37 41590.37 34658.64 34658.64 I 11887.75 11887.75 humana medicare advantage pos major esophageal disorders with mcc ms-drg 368 12011.24 12011.24 11493.96 11493.96 41590.37 41590.37 34658.64 34658.64 I 11887.75 11887.75 humana medicare advantage ppo major esophageal disorders with mcc ms-drg 368 12011.24 12011.24 11493.96 11493.96 41590.37 41590.37 34658.64 34658.64 I 11887.75 11887.75 humana medicare advantage hmo major gastrointestinal disorders and peritoneal infections with mcc ms-drg 371 10891.7 10891.7 7901.82 7901.82 58870.42 58870.42 49058.68 49058.68 I 10067.22 10067.22 humana medicare advantage hmo major gastrointestinal disorders and peritoneal infections with mcc ms-drg 371 10891.7 10891.7 7901.82 7901.82 58870.42 58870.42 49058.68 49058.68 I 10067.22 10067.22 humana medicare advantage pos major gastrointestinal disorders and peritoneal infections with mcc ms-drg 371 10891.7 10891.7 7901.82 7901.82 58870.42 58870.42 49058.68 49058.68 I 10067.22 10067.22 humana medicare advantage ppo major gastrointestinal disorders and peritoneal infections with mcc ms-drg 371 10891.7 10891.7 7901.82 7901.82 58870.42 58870.42 49058.68 49058.68 I 10067.22 10067.22 humana medicare advantage hmo Fragmented donor bone graft or placement of material to promote bone growth for spine surgery cpt 20930 10573.89 10573.89 5215.79 5215.79 74066.99 74066.99 61722.49 61722.49 O 10573.89 10573.89 humana medicare advantage hmo Fragmented donor bone graft or placement of material to promote bone growth for spine surgery cpt 20930 10573.89 10573.89 5215.79 5215.79 74066.99 74066.99 61722.49 61722.49 O 10573.89 10573.89 humana medicare advantage pos Fragmented donor bone graft or placement of material to promote bone growth for spine surgery cpt 20930 10573.89 10573.89 5215.79 5215.79 74066.99 74066.99 61722.49 61722.49 O 10573.89 10573.89 humana medicare advantage ppo Fragmented donor bone graft or placement of material to promote bone growth for spine surgery cpt 20930 10573.89 10573.89 5215.79 5215.79 74066.99 74066.99 61722.49 61722.49 O 10573.89 10573.89 humana medicare advantage hmo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6617.66 6617.66 humana medicare advantage hmo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6617.66 6617.66 humana medicare advantage pos gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6617.66 6617.66 humana medicare advantage ppo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6617.66 6617.66 humana medicare advantage hmo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 231.9 231.9 humana medicare advantage hmo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 231.9 231.9 humana medicare advantage pos Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 231.9 231.9 humana medicare advantage ppo Aspiration and/or injection of large joint or joint capsule cpt 20610 877.03 877.03 231.9 231.9 742.56 742.56 618.8 618.8 O 231.9 231.9 humana medicare advantage hmo complicated peptic ulcer with cc ms-drg 381 7221.97 7221.97 6149.37 6149.37 25309.24 25309.24 21091.03 21091.03 I 7221.97 7221.97 humana medicare advantage hmo complicated peptic ulcer with cc ms-drg 381 7221.97 7221.97 6149.37 6149.37 25309.24 25309.24 21091.03 21091.03 I 7221.97 7221.97 humana medicare advantage pos complicated peptic ulcer with cc ms-drg 381 7221.97 7221.97 6149.37 6149.37 25309.24 25309.24 21091.03 21091.03 I 7221.97 7221.97 humana medicare advantage ppo complicated peptic ulcer with cc ms-drg 381 7221.97 7221.97 6149.37 6149.37 25309.24 25309.24 21091.03 21091.03 I 7221.97 7221.97 humana medicare advantage hmo inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 6051.58 6051.58 humana medicare advantage hmo inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 6051.58 6051.58 humana medicare advantage pos inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 6051.58 6051.58 humana medicare advantage ppo inflammatory bowel disease with cc ms-drg 386 11750.65 11750.65 4738.54 4738.54 36145.84 36145.84 30121.53 30121.53 I 6051.58 6051.58 humana medicare advantage hmo Aspiration and/or injection of medium joint or joint capsule cpt 20605 660.04 660.04 660.04 660.04 3448.16 3448.16 2873.47 2873.47 E 660.04 660.04 humana medicare advantage hmo Aspiration and/or injection of medium joint or joint capsule cpt 20605 660.04 660.04 660.04 660.04 3448.16 3448.16 2873.47 2873.47 E 660.04 660.04 humana medicare advantage pos Aspiration and/or injection of medium joint or joint capsule cpt 20605 660.04 660.04 660.04 660.04 3448.16 3448.16 2873.47 2873.47 E 660.04 660.04 humana medicare advantage ppo Aspiration and/or injection of medium joint or joint capsule cpt 20605 660.04 660.04 660.04 660.04 3448.16 3448.16 2873.47 2873.47 E 660.04 660.04 humana medicare advantage hmo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 5432.62 5432.62 humana medicare advantage hmo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 5432.62 5432.62 humana medicare advantage pos gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 5432.62 5432.62 humana medicare advantage ppo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 5432.62 5432.62 humana medicare advantage hmo other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 6441.45 6441.45 humana medicare advantage hmo other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 6441.45 6441.45 humana medicare advantage pos other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 6441.45 6441.45 humana medicare advantage ppo other digestive system diagnoses with cc ms-drg 394 8388.74 8388.74 4580.56 4580.56 30617.81 30617.81 25514.84 25514.84 I 6441.45 6441.45 humana medicare advantage hmo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4639.61 4639.61 humana medicare advantage hmo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4639.61 4639.61 humana medicare advantage pos Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4639.61 4639.61 humana medicare advantage ppo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4639.61 4639.61 humana medicare advantage hmo malignancy of hepatobiliary system or pancreas with mcc ms-drg 435 10769.03 10769.03 5409.97 5409.97 33564.19 33564.19 27970.16 27970.16 I 10715.69 10715.69 humana medicare advantage hmo malignancy of hepatobiliary system or pancreas with mcc ms-drg 435 10769.03 10769.03 5409.97 5409.97 33564.19 33564.19 27970.16 27970.16 I 10715.69 10715.69 humana medicare advantage pos malignancy of hepatobiliary system or pancreas with mcc ms-drg 435 10769.03 10769.03 5409.97 5409.97 33564.19 33564.19 27970.16 27970.16 I 10715.69 10715.69 humana medicare advantage ppo malignancy of hepatobiliary system or pancreas with mcc ms-drg 435 10769.03 10769.03 5409.97 5409.97 33564.19 33564.19 27970.16 27970.16 I 10715.69 10715.69 humana medicare advantage hmo "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 1345.13 1345.13 humana medicare advantage hmo "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 1345.13 1345.13 humana medicare advantage pos "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 1345.13 1345.13 humana medicare advantage ppo "Biopsy of breast accessed through the skin with ultrasound guidance, additional lesion" cpt 19084 4003.45 4003.45 1196.5 1196.5 12652.85 12652.85 10544.04 10544.04 O 1345.13 1345.13 humana medicare advantage hmo disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 6497.96 6497.96 humana medicare advantage hmo disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 6497.96 6497.96 humana medicare advantage pos disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 6497.96 6497.96 humana medicare advantage ppo disorders of pancreas except malignancy with mcc ms-drg 438 25700.17 25700.17 6497.96 6497.96 50989.15 50989.15 42490.96 42490.96 I 6497.96 6497.96 humana medicare advantage hmo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1345.13 1345.13 humana medicare advantage hmo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1345.13 1345.13 humana medicare advantage pos "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1345.13 1345.13 humana medicare advantage ppo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 1345.13 1345.13 humana medicare advantage hmo "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with cc" ms-drg 442 6432.48 6432.48 2765.26 2765.26 15198.22 15198.22 12665.18 12665.18 I 6414.99 6414.99 humana medicare advantage hmo "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with cc" ms-drg 442 6432.48 6432.48 2765.26 2765.26 15198.22 15198.22 12665.18 12665.18 I 6414.99 6414.99 humana medicare advantage pos "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with cc" ms-drg 442 6432.48 6432.48 2765.26 2765.26 15198.22 15198.22 12665.18 12665.18 I 6414.99 6414.99 humana medicare advantage ppo "disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with cc" ms-drg 442 6432.48 6432.48 2765.26 2765.26 15198.22 15198.22 12665.18 12665.18 I 6414.99 6414.99 humana medicare advantage hmo "Biopsy of breast accessed through the skin with stereotactic guidance, first lesion" cpt 19081 1215.96 1215.96 1215.96 1215.96 11913.47 11913.47 9927.89 9927.89 O 1215.96 1215.96 humana medicare advantage hmo "Biopsy of breast accessed through the skin with stereotactic guidance, first lesion" cpt 19081 1215.96 1215.96 1215.96 1215.96 11913.47 11913.47 9927.89 9927.89 O 1215.96 1215.96 humana medicare advantage pos "Biopsy of breast accessed through the skin with stereotactic guidance, first lesion" cpt 19081 1215.96 1215.96 1215.96 1215.96 11913.47 11913.47 9927.89 9927.89 O 1215.96 1215.96 humana medicare advantage ppo "Biopsy of breast accessed through the skin with stereotactic guidance, first lesion" cpt 19081 1215.96 1215.96 1215.96 1215.96 11913.47 11913.47 9927.89 9927.89 O 1215.96 1215.96 humana medicare advantage hmo wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with cc ms-drg 464 17839.18 17839.18 10570 10570 76750.34 76750.34 63958.62 63958.62 I 10570 10570 humana medicare advantage hmo wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with cc ms-drg 464 17839.18 17839.18 10570 10570 76750.34 76750.34 63958.62 63958.62 I 10570 10570 humana medicare advantage pos wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with cc ms-drg 464 17839.18 17839.18 10570 10570 76750.34 76750.34 63958.62 63958.62 I 10570 10570 humana medicare advantage ppo wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with cc ms-drg 464 17839.18 17839.18 10570 10570 76750.34 76750.34 63958.62 63958.62 I 10570 10570 humana medicare advantage hmo revision of hip or knee replacement with cc ms-drg 467 117942.4 117942.4 14037.35 14037.35 102567.41 102567.41 85472.84 85472.84 I 20754.42 20754.42 humana medicare advantage hmo revision of hip or knee replacement with cc ms-drg 467 117942.4 117942.4 14037.35 14037.35 102567.41 102567.41 85472.84 85472.84 I 20754.42 20754.42 humana medicare advantage pos revision of hip or knee replacement with cc ms-drg 467 117942.4 117942.4 14037.35 14037.35 102567.41 102567.41 85472.84 85472.84 I 20754.42 20754.42 humana medicare advantage ppo revision of hip or knee replacement with cc ms-drg 467 117942.4 117942.4 14037.35 14037.35 102567.41 102567.41 85472.84 85472.84 I 20754.42 20754.42 humana medicare advantage hmo cervical spinal fusion with mcc ms-drg 471 46211.54 46211.54 27832.43 27832.43 101079.62 101079.62 84233.02 84233.02 I 29284.18 29284.18 humana medicare advantage hmo cervical spinal fusion with mcc ms-drg 471 46211.54 46211.54 27832.43 27832.43 101079.62 101079.62 84233.02 84233.02 I 29284.18 29284.18 humana medicare advantage pos cervical spinal fusion with mcc ms-drg 471 46211.54 46211.54 27832.43 27832.43 101079.62 101079.62 84233.02 84233.02 I 29284.18 29284.18 humana medicare advantage ppo cervical spinal fusion with mcc ms-drg 471 46211.54 46211.54 27832.43 27832.43 101079.62 101079.62 84233.02 84233.02 I 29284.18 29284.18 humana medicare advantage hmo hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 21300.97 21300.97 humana medicare advantage hmo hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 21300.97 21300.97 humana medicare advantage pos hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 21300.97 21300.97 humana medicare advantage ppo hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 21300.97 21300.97 humana medicare advantage hmo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 12770.33 12770.33 humana medicare advantage hmo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 12770.33 12770.33 humana medicare advantage pos hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 12770.33 12770.33 humana medicare advantage ppo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 12770.33 12770.33 humana medicare advantage hmo Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 540.4 540.4 humana medicare advantage hmo Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 540.4 540.4 humana medicare advantage pos Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 540.4 540.4 humana medicare advantage ppo Aspiration of breast cyst cpt 19000 4127.82 4127.82 540.4 540.4 2462.56 2462.56 2052.13 2052.13 O 540.4 540.4 humana medicare advantage hmo "Skin, mucus membrane and beneath the skin procedure" cpt 17999 3760.63 3760.63 1206.23 1206.23 23434.01 23434.01 19528.34 19528.34 O 1215.96 1215.96 humana medicare advantage hmo "Skin, mucus membrane and beneath the skin procedure" cpt 17999 3760.63 3760.63 1206.23 1206.23 23434.01 23434.01 19528.34 19528.34 O 1215.96 1215.96 humana medicare advantage pos "Skin, mucus membrane and beneath the skin procedure" cpt 17999 3760.63 3760.63 1206.23 1206.23 23434.01 23434.01 19528.34 19528.34 O 1215.96 1215.96 humana medicare advantage ppo "Skin, mucus membrane and beneath the skin procedure" cpt 17999 3760.63 3760.63 1206.23 1206.23 23434.01 23434.01 19528.34 19528.34 O 1215.96 1215.96 humana medicare advantage hmo major joint or limb reattachment procedures of upper extremities ms-drg 483 14813.24 14813.24 14629.54 14629.54 91939.14 91939.14 76615.95 76615.95 I 14629.54 14629.54 humana medicare advantage hmo major joint or limb reattachment procedures of upper extremities ms-drg 483 14813.24 14813.24 14629.54 14629.54 91939.14 91939.14 76615.95 76615.95 I 14629.54 14629.54 humana medicare advantage pos major joint or limb reattachment procedures of upper extremities ms-drg 483 14813.24 14813.24 14629.54 14629.54 91939.14 91939.14 76615.95 76615.95 I 14629.54 14629.54 humana medicare advantage ppo major joint or limb reattachment procedures of upper extremities ms-drg 483 14813.24 14813.24 14629.54 14629.54 91939.14 91939.14 76615.95 76615.95 I 14629.54 14629.54 humana medicare advantage hmo Muscle flap wound repair at trunk cpt 15734 7309.85 7309.85 7309.85 7309.85 30295.2 30295.2 25246 25246 O 7309.85 7309.85 humana medicare advantage hmo Muscle flap wound repair at trunk cpt 15734 7309.85 7309.85 7309.85 7309.85 30295.2 30295.2 25246 25246 O 7309.85 7309.85 humana medicare advantage pos Muscle flap wound repair at trunk cpt 15734 7309.85 7309.85 7309.85 7309.85 30295.2 30295.2 25246 25246 O 7309.85 7309.85 humana medicare advantage ppo Muscle flap wound repair at trunk cpt 15734 7309.85 7309.85 7309.85 7309.85 30295.2 30295.2 25246 25246 O 7309.85 7309.85 humana medicare advantage hmo back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 8532.4 8532.4 humana medicare advantage hmo back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 8532.4 8532.4 humana medicare advantage pos back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 8532.4 8532.4 humana medicare advantage ppo back and neck procedures except spinal fusion without cc/mcc ms-drg 520 12494.82 12494.82 6675.11 6675.11 38066.74 38066.74 31722.28 31722.28 I 8532.4 8532.4 humana medicare advantage hmo hip replacement with principal diagnosis of hip fracture without mcc ms-drg 522 13434.58 13434.58 13309.54 13309.54 86336.41 86336.41 71947.01 71947.01 I 13309.54 13309.54 humana medicare advantage hmo hip replacement with principal diagnosis of hip fracture without mcc ms-drg 522 13434.58 13434.58 13309.54 13309.54 86336.41 86336.41 71947.01 71947.01 I 13309.54 13309.54 humana medicare advantage pos hip replacement with principal diagnosis of hip fracture without mcc ms-drg 522 13434.58 13434.58 13309.54 13309.54 86336.41 86336.41 71947.01 71947.01 I 13309.54 13309.54 humana medicare advantage ppo hip replacement with principal diagnosis of hip fracture without mcc ms-drg 522 13434.58 13434.58 13309.54 13309.54 86336.41 86336.41 71947.01 71947.01 I 13309.54 13309.54 humana medicare advantage hmo connective tissue disorders with mcc ms-drg 545 15159.26 15159.26 14109.06 14109.06 97336.54 97336.54 81113.78 81113.78 I 15159.26 15159.26 humana medicare advantage hmo connective tissue disorders with mcc ms-drg 545 15159.26 15159.26 14109.06 14109.06 97336.54 97336.54 81113.78 81113.78 I 15159.26 15159.26 humana medicare advantage pos connective tissue disorders with mcc ms-drg 545 15159.26 15159.26 14109.06 14109.06 97336.54 97336.54 81113.78 81113.78 I 15159.26 15159.26 humana medicare advantage ppo connective tissue disorders with mcc ms-drg 545 15159.26 15159.26 14109.06 14109.06 97336.54 97336.54 81113.78 81113.78 I 15159.26 15159.26 humana medicare advantage hmo medical back problems with mcc ms-drg 551 10158.98 10158.98 6280.8 6280.8 39910.76 39910.76 33258.97 33258.97 I 9936.8 9936.8 humana medicare advantage hmo medical back problems with mcc ms-drg 551 10158.98 10158.98 6280.8 6280.8 39910.76 39910.76 33258.97 33258.97 I 9936.8 9936.8 humana medicare advantage pos medical back problems with mcc ms-drg 551 10158.98 10158.98 6280.8 6280.8 39910.76 39910.76 33258.97 33258.97 I 9936.8 9936.8 humana medicare advantage ppo medical back problems with mcc ms-drg 551 10158.98 10158.98 6280.8 6280.8 39910.76 39910.76 33258.97 33258.97 I 9936.8 9936.8 humana medicare advantage hmo "fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc" ms-drg 563 5760.45 5760.45 4113.82 4113.82 19610.36 19610.36 16341.97 16341.97 I 5305.67 5305.67 humana medicare advantage hmo "fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc" ms-drg 563 5760.45 5760.45 4113.82 4113.82 19610.36 19610.36 16341.97 16341.97 I 5305.67 5305.67 humana medicare advantage pos "fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc" ms-drg 563 5760.45 5760.45 4113.82 4113.82 19610.36 19610.36 16341.97 16341.97 I 5305.67 5305.67 humana medicare advantage ppo "fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc" ms-drg 563 5760.45 5760.45 4113.82 4113.82 19610.36 19610.36 16341.97 16341.97 I 5305.67 5305.67 humana medicare advantage hmo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 10217.88 10217.88 humana medicare advantage hmo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 10217.88 10217.88 humana medicare advantage pos "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 10217.88 10217.88 humana medicare advantage ppo "other skin, subcutaneous tissue and breast procedures with cc" ms-drg 580 13853.94 13853.94 2320.4 2320.4 60281.84 60281.84 50234.87 50234.87 I 10217.88 10217.88 humana medicare advantage hmo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 517.64 517.64 197.85 197.85 1425.3 1425.3 1187.75 1187.75 E 473.8 473.8 humana medicare advantage hmo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 517.64 517.64 197.85 197.85 1425.3 1425.3 1187.75 1187.75 E 473.8 473.8 humana medicare advantage pos "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 517.64 517.64 197.85 197.85 1425.3 1425.3 1187.75 1187.75 E 473.8 473.8 humana medicare advantage ppo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 517.64 517.64 197.85 197.85 1425.3 1425.3 1187.75 1187.75 E 473.8 473.8 humana medicare advantage hmo cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 9125.6 9125.6 humana medicare advantage hmo cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 9125.6 9125.6 humana medicare advantage pos cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 9125.6 9125.6 humana medicare advantage ppo cellulitis with mcc ms-drg 602 16664.06 16664.06 5542.21 5542.21 52542.07 52542.07 43785.06 43785.06 I 9125.6 9125.6 humana medicare advantage hmo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 315.35 315.35 humana medicare advantage hmo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 315.35 315.35 humana medicare advantage pos "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 315.35 315.35 humana medicare advantage ppo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 315.35 315.35 humana medicare advantage hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 461.23 461.23 humana medicare advantage hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 461.23 461.23 humana medicare advantage pos "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 461.23 461.23 humana medicare advantage ppo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 461.23 461.23 humana medicare advantage hmo "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 11696.3 11696.3 humana medicare advantage hmo "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 11696.3 11696.3 humana medicare advantage pos "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 11696.3 11696.3 humana medicare advantage ppo "amputation of lower limb for endocrine, nutritional and metabolic disorders with cc" ms-drg 617 19091.29 19091.29 10377.05 10377.05 53486.18 53486.18 44571.82 44571.82 I 11696.3 11696.3 humana medicare advantage hmo "skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with mcc" ms-drg 622 22420.04 22420.04 22420.04 22420.04 69318.7 69318.7 57765.58 57765.58 I 22420.04 22420.04 humana medicare advantage hmo "skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with mcc" ms-drg 622 22420.04 22420.04 22420.04 22420.04 69318.7 69318.7 57765.58 57765.58 I 22420.04 22420.04 humana medicare advantage pos "skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with mcc" ms-drg 622 22420.04 22420.04 22420.04 22420.04 69318.7 69318.7 57765.58 57765.58 I 22420.04 22420.04 humana medicare advantage ppo "skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with mcc" ms-drg 622 22420.04 22420.04 22420.04 22420.04 69318.7 69318.7 57765.58 57765.58 I 22420.04 22420.04 humana medicare advantage hmo "other endocrine, nutritional and metabolic o.r. procedures with cc" ms-drg 629 14310.16 14310.16 9468.97 9468.97 58346.14 58346.14 48621.78 48621.78 I 9468.97 9468.97 humana medicare advantage hmo "other endocrine, nutritional and metabolic o.r. procedures with cc" ms-drg 629 14310.16 14310.16 9468.97 9468.97 58346.14 58346.14 48621.78 48621.78 I 9468.97 9468.97 humana medicare advantage pos "other endocrine, nutritional and metabolic o.r. procedures with cc" ms-drg 629 14310.16 14310.16 9468.97 9468.97 58346.14 58346.14 48621.78 48621.78 I 9468.97 9468.97 humana medicare advantage ppo "other endocrine, nutritional and metabolic o.r. procedures with cc" ms-drg 629 14310.16 14310.16 9468.97 9468.97 58346.14 58346.14 48621.78 48621.78 I 9468.97 9468.97 humana medicare advantage hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 8835.1 8835.1 humana medicare advantage hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 8835.1 8835.1 humana medicare advantage pos diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 8835.1 8835.1 humana medicare advantage ppo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 8835.1 8835.1 humana medicare advantage hmo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6055.18 6055.18 humana medicare advantage hmo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6055.18 6055.18 humana medicare advantage pos diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6055.18 6055.18 humana medicare advantage ppo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 6055.18 6055.18 humana medicare advantage hmo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 410.93 410.93 humana medicare advantage hmo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 410.93 410.93 humana medicare advantage pos "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 410.93 410.93 humana medicare advantage ppo "Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs" cpt 12001 1130.86 1130.86 197.85 197.85 1247.68 1247.68 1039.73 1039.73 E 410.93 410.93 humana medicare advantage hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 7438.56 7438.56 humana medicare advantage hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 7438.56 7438.56 humana medicare advantage pos "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 7438.56 7438.56 humana medicare advantage ppo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 7438.56 7438.56 humana medicare advantage hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5227.82 5227.82 humana medicare advantage hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5227.82 5227.82 humana medicare advantage pos "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5227.82 5227.82 humana medicare advantage ppo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 5227.82 5227.82 humana medicare advantage hmo endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 6214.46 6214.46 humana medicare advantage hmo endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 6214.46 6214.46 humana medicare advantage pos endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 6214.46 6214.46 humana medicare advantage ppo endocrine disorders with cc ms-drg 644 19059.25 19059.25 6214.46 6214.46 25664.1 25664.1 21386.75 21386.75 I 6214.46 6214.46 humana medicare advantage hmo transurethral procedures with cc ms-drg 669 9728.02 9728.02 9728.02 9728.02 81339.89 81339.89 67783.24 67783.24 I 9728.02 9728.02 humana medicare advantage hmo transurethral procedures with cc ms-drg 669 9728.02 9728.02 9728.02 9728.02 81339.89 81339.89 67783.24 67783.24 I 9728.02 9728.02 humana medicare advantage pos transurethral procedures with cc ms-drg 669 9728.02 9728.02 9728.02 9728.02 81339.89 81339.89 67783.24 67783.24 I 9728.02 9728.02 humana medicare advantage ppo transurethral procedures with cc ms-drg 669 9728.02 9728.02 9728.02 9728.02 81339.89 81339.89 67783.24 67783.24 I 9728.02 9728.02 humana medicare advantage hmo "Removal of malignant growth (3.1 to 4 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11624 2890.67 2890.67 1215.96 1215.96 19505.98 19505.98 16254.98 16254.98 O 1215.96 1215.96 humana medicare advantage hmo "Removal of malignant growth (3.1 to 4 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11624 2890.67 2890.67 1215.96 1215.96 19505.98 19505.98 16254.98 16254.98 O 1215.96 1215.96 humana medicare advantage pos "Removal of malignant growth (3.1 to 4 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11624 2890.67 2890.67 1215.96 1215.96 19505.98 19505.98 16254.98 16254.98 O 1215.96 1215.96 humana medicare advantage ppo "Removal of malignant growth (3.1 to 4 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11624 2890.67 2890.67 1215.96 1215.96 19505.98 19505.98 16254.98 16254.98 O 1215.96 1215.96 humana medicare advantage hmo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 8894.22 8894.22 humana medicare advantage hmo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 8894.22 8894.22 humana medicare advantage pos renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 8894.22 8894.22 humana medicare advantage ppo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 8894.22 8894.22 humana medicare advantage hmo "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 1215.96 1215.96 humana medicare advantage hmo "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 1215.96 1215.96 humana medicare advantage pos "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 1215.96 1215.96 humana medicare advantage ppo "Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs" cpt 11606 5337.57 5337.57 1215.96 1215.96 16745.52 16745.52 13954.6 13954.6 O 1215.96 1215.96 humana medicare advantage hmo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6211.69 6211.69 humana medicare advantage hmo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6211.69 6211.69 humana medicare advantage pos renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6211.69 6211.69 humana medicare advantage ppo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6211.69 6211.69 humana medicare advantage hmo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 2628.54 2628.54 humana medicare advantage hmo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 2628.54 2628.54 humana medicare advantage pos other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 2628.54 2628.54 humana medicare advantage ppo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 2628.54 2628.54 humana medicare advantage hmo "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 2054.26 2054.26 humana medicare advantage hmo "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 2054.26 2054.26 humana medicare advantage pos "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 2054.26 2054.26 humana medicare advantage ppo "Removal of growth (4.0 centimeters) of the trunk, arms, or legs" cpt 11406 4476.04 4476.04 1215.96 1215.96 17348.3 17348.3 14456.92 14456.92 O 2054.26 2054.26 humana medicare advantage hmo "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2054.26 2054.26 humana medicare advantage hmo "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2054.26 2054.26 humana medicare advantage pos "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2054.26 2054.26 humana medicare advantage ppo "Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs" cpt 11404 2173.47 2173.47 2054.26 2054.26 16481.42 16481.42 13734.52 13734.52 O 2054.26 2054.26 humana medicare advantage hmo "Removal of growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs" cpt 11403 2054.26 2054.26 868.45 868.45 15294.19 15294.19 12745.16 12745.16 O 2054.26 2054.26 humana medicare advantage hmo "Removal of growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs" cpt 11403 2054.26 2054.26 868.45 868.45 15294.19 15294.19 12745.16 12745.16 O 2054.26 2054.26 humana medicare advantage pos "Removal of growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs" cpt 11403 2054.26 2054.26 868.45 868.45 15294.19 15294.19 12745.16 12745.16 O 2054.26 2054.26 humana medicare advantage ppo "Removal of growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs" cpt 11403 2054.26 2054.26 868.45 868.45 15294.19 15294.19 12745.16 12745.16 O 2054.26 2054.26 humana medicare advantage hmo Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1192.54 1192.54 humana medicare advantage hmo Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1192.54 1192.54 humana medicare advantage pos Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1192.54 1192.54 humana medicare advantage ppo Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 1192.54 1192.54 humana medicare advantage hmo Removal of skin and/or muscle first 20 sq cm or less cpt 11043 440.3 440.3 433.26 433.26 2436.26 2436.26 2030.22 2030.22 O 440.3 440.3 humana medicare advantage hmo Removal of skin and/or muscle first 20 sq cm or less cpt 11043 440.3 440.3 433.26 433.26 2436.26 2436.26 2030.22 2030.22 O 440.3 440.3 humana medicare advantage pos Removal of skin and/or muscle first 20 sq cm or less cpt 11043 440.3 440.3 433.26 433.26 2436.26 2436.26 2030.22 2030.22 O 440.3 440.3 humana medicare advantage ppo Removal of skin and/or muscle first 20 sq cm or less cpt 11043 440.3 440.3 433.26 433.26 2436.26 2436.26 2030.22 2030.22 O 440.3 440.3 humana medicare advantage hmo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 humana medicare advantage hmo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 humana medicare advantage pos Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 humana medicare advantage ppo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 283.05 283.05 humana medicare advantage hmo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 6599.64 6599.64 humana medicare advantage hmo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 6599.64 6599.64 humana medicare advantage pos red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 6599.64 6599.64 humana medicare advantage ppo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 6599.64 6599.64 humana medicare advantage hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 humana medicare advantage hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 humana medicare advantage pos Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 humana medicare advantage ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 283.05 283.05 humana medicare advantage hmo acute leukemia without major o.r. procedures with mcc ms-drg 834 23517.21 23517.21 17804.61 17804.61 58562.51 58562.51 48802.09 48802.09 I 23517.21 23517.21 humana medicare advantage hmo acute leukemia without major o.r. procedures with mcc ms-drg 834 23517.21 23517.21 17804.61 17804.61 58562.51 58562.51 48802.09 48802.09 I 23517.21 23517.21 humana medicare advantage pos acute leukemia without major o.r. procedures with mcc ms-drg 834 23517.21 23517.21 17804.61 17804.61 58562.51 58562.51 48802.09 48802.09 I 23517.21 23517.21 humana medicare advantage ppo acute leukemia without major o.r. procedures with mcc ms-drg 834 23517.21 23517.21 17804.61 17804.61 58562.51 58562.51 48802.09 48802.09 I 23517.21 23517.21 humana medicare advantage hmo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 29630.17 29630.17 humana medicare advantage hmo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 29630.17 29630.17 humana medicare advantage pos infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 29630.17 29630.17 humana medicare advantage ppo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 29630.17 29630.17 humana medicare advantage hmo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 470.54 470.54 humana medicare advantage hmo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 470.54 470.54 humana medicare advantage pos Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 470.54 470.54 humana medicare advantage ppo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 470.54 470.54 humana medicare advantage hmo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 13097.4 13097.4 humana medicare advantage hmo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 13097.4 13097.4 humana medicare advantage pos infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 13097.4 13097.4 humana medicare advantage ppo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 13097.4 13097.4 humana medicare advantage hmo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 11580.12 11580.12 humana medicare advantage hmo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 11580.12 11580.12 humana medicare advantage pos postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 11580.12 11580.12 humana medicare advantage ppo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 11580.12 11580.12 humana medicare advantage hmo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 537.95 537.95 humana medicare advantage hmo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 537.95 537.95 humana medicare advantage pos Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 537.95 537.95 humana medicare advantage ppo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 537.95 537.95 humana medicare advantage hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 36773.4 36773.4 humana medicare advantage hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 36773.4 36773.4 humana medicare advantage pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 36773.4 36773.4 humana medicare advantage ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 36773.4 36773.4 humana medicare advantage hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11460.87 11460.87 humana medicare advantage hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11460.87 11460.87 humana medicare advantage pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11460.87 11460.87 humana medicare advantage ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 11460.87 11460.87 humana medicare advantage hmo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 326.12 326.12 humana medicare advantage hmo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 326.12 326.12 humana medicare advantage pos Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 326.12 326.12 humana medicare advantage ppo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 326.12 326.12 humana medicare advantage hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6441.29 6441.29 humana medicare advantage hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6441.29 6441.29 humana medicare advantage pos septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6441.29 6441.29 humana medicare advantage ppo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 6441.29 6441.29 humana medicare advantage hmo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 99.29 99.29 humana medicare advantage hmo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 99.29 99.29 humana medicare advantage pos Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 99.29 99.29 humana medicare advantage ppo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 99.29 99.29 humana medicare advantage hmo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 4969.46 4969.46 humana medicare advantage hmo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 4969.46 4969.46 humana medicare advantage pos depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 4969.46 4969.46 humana medicare advantage ppo depressive neuroses ms-drg 881 5854.77 5854.77 1743.69 1743.69 17531.84 17531.84 14609.87 14609.87 I 4969.46 4969.46 humana medicare advantage hmo neuroses except depressive ms-drg 882 2988 2988 1738.02 1738.02 14677.57 14677.57 12231.31 12231.31 I 2988 2988 humana medicare advantage hmo neuroses except depressive ms-drg 882 2988 2988 1738.02 1738.02 14677.57 14677.57 12231.31 12231.31 I 2988 2988 humana medicare advantage pos neuroses except depressive ms-drg 882 2988 2988 1738.02 1738.02 14677.57 14677.57 12231.31 12231.31 I 2988 2988 humana medicare advantage ppo neuroses except depressive ms-drg 882 2988 2988 1738.02 1738.02 14677.57 14677.57 12231.31 12231.31 I 2988 2988 humana medicare advantage hmo X-ray of shoulder blade cpt 73010 97.3 97.3 15.56 15.56 256.8 256.8 214 214 O 97.3 97.3 humana medicare advantage hmo X-ray of shoulder blade cpt 73010 97.3 97.3 15.56 15.56 256.8 256.8 214 214 O 97.3 97.3 humana medicare advantage pos X-ray of shoulder blade cpt 73010 97.3 97.3 15.56 15.56 256.8 256.8 214 214 O 97.3 97.3 humana medicare advantage ppo X-ray of shoulder blade cpt 73010 97.3 97.3 15.56 15.56 256.8 256.8 214 214 O 97.3 97.3 humana medicare advantage hmo psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 6808.2 6808.2 humana medicare advantage hmo psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 6808.2 6808.2 humana medicare advantage pos psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 6808.2 6808.2 humana medicare advantage ppo psychoses ms-drg 885 8042.08 8042.08 1842.42 1842.42 18156.65 18156.65 15130.54 15130.54 I 6808.2 6808.2 humana medicare advantage hmo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage hmo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage pos CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage ppo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 99.29 99.29 humana medicare advantage hmo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 4477.46 4477.46 humana medicare advantage hmo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 4477.46 4477.46 humana medicare advantage pos "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 4477.46 4477.46 humana medicare advantage ppo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 4477.46 4477.46 humana medicare advantage hmo CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 210.13 210.13 humana medicare advantage hmo CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 210.13 210.13 humana medicare advantage pos CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 210.13 210.13 humana medicare advantage ppo CT scan of face cpt 70486 639.16 639.16 81.2 81.2 1366.13 1366.13 1138.44 1138.44 E 210.13 210.13 humana medicare advantage hmo other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 12452.88 12452.88 humana medicare advantage hmo other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 12452.88 12452.88 humana medicare advantage pos other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 12452.88 12452.88 humana medicare advantage ppo other o.r. procedures for injuries with cc ms-drg 908 16148.43 16148.43 6226.41 6226.41 54024 54024 45020 45020 I 12452.88 12452.88 humana medicare advantage hmo allergic reactions without mcc ms-drg 916 4747.61 4747.61 1686.46 1686.46 34418.34 34418.34 28681.95 28681.95 I 4645 4645 humana medicare advantage hmo allergic reactions without mcc ms-drg 916 4747.61 4747.61 1686.46 1686.46 34418.34 34418.34 28681.95 28681.95 I 4645 4645 humana medicare advantage pos allergic reactions without mcc ms-drg 916 4747.61 4747.61 1686.46 1686.46 34418.34 34418.34 28681.95 28681.95 I 4645 4645 humana medicare advantage ppo allergic reactions without mcc ms-drg 916 4747.61 4747.61 1686.46 1686.46 34418.34 34418.34 28681.95 28681.95 I 4645 4645 humana medicare advantage hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 14.7 14.7 humana medicare advantage hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 14.7 14.7 humana medicare advantage pos "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 14.7 14.7 humana medicare advantage ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 14.7 14.7 humana medicare advantage hmo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 9.3 9.3 humana medicare advantage hmo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 9.3 9.3 humana medicare advantage pos Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 9.3 9.3 humana medicare advantage ppo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 9.3 9.3 humana medicare advantage hmo Gastrin (GI tract hormone) level cpt 82941 17.63 17.63 17.46 17.46 128.47 128.47 107.06 107.06 O 17.63 17.63 humana medicare advantage hmo Gastrin (GI tract hormone) level cpt 82941 17.63 17.63 17.46 17.46 128.47 128.47 107.06 107.06 O 17.63 17.63 humana medicare advantage pos Gastrin (GI tract hormone) level cpt 82941 17.63 17.63 17.46 17.46 128.47 128.47 107.06 107.06 O 17.63 17.63 humana medicare advantage ppo Gastrin (GI tract hormone) level cpt 82941 17.63 17.63 17.46 17.46 128.47 128.47 107.06 107.06 O 17.63 17.63 humana medicare advantage hmo Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 3.93 3.93 humana medicare advantage hmo Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 3.93 3.93 humana medicare advantage pos Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 3.93 3.93 humana medicare advantage ppo Glucose (sugar) level on body fluid cpt 82945 78.89 78.89 3.5 3.5 117.12 117.12 97.6 97.6 O 3.93 3.93 humana medicare advantage hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 13.63 13.63 humana medicare advantage hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 13.63 13.63 humana medicare advantage pos Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 13.63 13.63 humana medicare advantage ppo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 13.63 13.63 humana medicare advantage hmo Blood glucose (sugar) level cpt 82947 3.93 3.93 3.85 3.85 117.12 117.12 97.6 97.6 E 3.93 3.93 humana medicare advantage hmo Blood glucose (sugar) level cpt 82947 3.93 3.93 3.85 3.85 117.12 117.12 97.6 97.6 E 3.93 3.93 humana medicare advantage pos Blood glucose (sugar) level cpt 82947 3.93 3.93 3.85 3.85 117.12 117.12 97.6 97.6 E 3.93 3.93 humana medicare advantage ppo Blood glucose (sugar) level cpt 82947 3.93 3.93 3.85 3.85 117.12 117.12 97.6 97.6 E 3.93 3.93 humana medicare advantage hmo "Stool fat or lipids analysis, qualitative" cpt 82705 5.1 5.1 5.1 5.1 16.98 16.98 14.15 14.15 O 5.1 5.1 humana medicare advantage hmo "Stool fat or lipids analysis, qualitative" cpt 82705 5.1 5.1 5.1 5.1 16.98 16.98 14.15 14.15 O 5.1 5.1 humana medicare advantage pos "Stool fat or lipids analysis, qualitative" cpt 82705 5.1 5.1 5.1 5.1 16.98 16.98 14.15 14.15 O 5.1 5.1 humana medicare advantage ppo "Stool fat or lipids analysis, qualitative" cpt 82705 5.1 5.1 5.1 5.1 16.98 16.98 14.15 14.15 O 5.1 5.1 humana medicare advantage hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 12.87 12.87 humana medicare advantage hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 12.87 12.87 humana medicare advantage pos "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 12.87 12.87 humana medicare advantage ppo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 12.87 12.87 humana medicare advantage hmo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 18.79 18.79 humana medicare advantage hmo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 18.79 18.79 humana medicare advantage pos Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 18.79 18.79 humana medicare advantage ppo Erythropoietin (protein) level cpt 82668 50.06 50.06 16.99 16.99 160.27 160.27 133.56 133.56 O 18.79 18.79 humana medicare advantage hmo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 320.9 320.9 tricare ppo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 320.9 320.9 tricare pos Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 275.05 275.05 tricare ppo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 275.05 275.05 tricare pos Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 167.1 167.1 tricare ppo Fetal fibronectin (protein) analysis cpt 82731 348.55 348.55 57.29 57.29 609.54 609.54 507.95 507.95 O 167.1 167.1 tricare pos Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 21.84 21.84 tricare ppo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 21.84 21.84 tricare pos Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 176.99 176.99 tricare ppo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 176.99 176.99 tricare pos "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 229.19 229.19 tricare ppo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 229.19 229.19 tricare pos infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 953.05 953.05 uhc medicare advantage ppo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 953.05 953.05 uhc medicare advantage hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3312.01 3312.01 united health care ppo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3312.01 3312.01 united health care pos "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3312.01 3312.01 united health care hmo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3312.01 3312.01 united health care epo "Walking training to 1 or more areas, each 15 minutes" cpt 97116 3531.48 3531.48 421.02 421.02 5376.74 5376.74 4480.62 4480.62 O 3312.01 3312.01 united health care hmo Ultrasound of scrotum cpt 76870 365.07 365.07 61.82 61.82 569.86 569.86 474.88 474.88 E 365.07 365.07 united health care ppo Ultrasound of scrotum cpt 76870 365.07 365.07 61.82 61.82 569.86 569.86 474.88 474.88 E 365.07 365.07 united health care pos Ultrasound of scrotum cpt 76870 365.07 365.07 61.82 61.82 569.86 569.86 474.88 474.88 E 365.07 365.07 united health care hmo Ultrasound of scrotum cpt 76870 365.07 365.07 61.82 61.82 569.86 569.86 474.88 474.88 E 365.07 365.07 united health care epo Ultrasound of scrotum cpt 76870 365.07 365.07 61.82 61.82 569.86 569.86 474.88 474.88 E 365.07 365.07 united health care hmo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1415.24 1415.24 united health care ppo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1415.24 1415.24 united health care pos "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1415.24 1415.24 united health care hmo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1415.24 1415.24 united health care epo "Injections of lower or sacral spine facet joint using imaging guidance, single level" cpt 64493 3530.58 3530.58 657.1 657.1 4789.46 4789.46 3991.22 3991.22 O 1415.24 1415.24 united health care hmo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 5714.16 5714.16 united health care ppo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 5714.16 5714.16 united health care pos drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 5714.16 5714.16 united health care hmo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 5714.16 5714.16 united health care epo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 5714.16 5714.16 united health care hmo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 3812.03 3812.03 united health care ppo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 3812.03 3812.03 united health care pos "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 3812.03 3812.03 united health care hmo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 3812.03 3812.03 united health care epo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 3812.03 3812.03 united health care hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 2189.43 2189.43 united health care ppo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 2189.43 2189.43 united health care pos "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 2189.43 2189.43 united health care hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 2189.43 2189.43 united health care epo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, each additional level" cpt 64484 2189.43 2189.43 657.1 657.1 13287.97 13287.97 11073.31 11073.31 O 2189.43 2189.43 united health care hmo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 3420.82 3420.82 united health care ppo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 3420.82 3420.82 united health care pos "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 3420.82 3420.82 united health care hmo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 3420.82 3420.82 united health care epo "Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" cpt 97112 3420.82 3420.82 195.16 195.16 4791.22 4791.22 3992.68 3992.68 O 3420.82 3420.82 united health care hmo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 2686.91 2686.91 united health care ppo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 2686.91 2686.91 united health care pos "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 2686.91 2686.91 united health care hmo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 2686.91 2686.91 united health care epo "Application of ultrasound to 1 or more areas, each 15 minutes" cpt 97035 2686.91 2686.91 496.33 496.33 4441.82 4441.82 3701.52 3701.52 O 2686.91 2686.91 united health care hmo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 2686.91 2686.91 united health care ppo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 2686.91 2686.91 united health care pos Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 2686.91 2686.91 united health care hmo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 2686.91 2686.91 united health care epo Application of hot wax bath to 1 or more areas cpt 97018 2686.91 2686.91 335.64 335.64 3236.4 3236.4 2697 2697 O 2686.91 2686.91 united health care hmo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2712.74 2712.74 united health care ppo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2712.74 2712.74 united health care pos acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2712.74 2712.74 united health care hmo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2712.74 2712.74 united health care epo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2712.74 2712.74 united health care hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care pos Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care epo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 10344.21 10344.21 united health care ppo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 10344.21 10344.21 united health care pos acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 10344.21 10344.21 united health care hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 10344.21 10344.21 united health care epo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 10344.21 10344.21 united health care hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 7348.19 7348.19 united health care ppo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 7348.19 7348.19 united health care pos Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 7348.19 7348.19 united health care hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 7348.19 7348.19 united health care epo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 7348.19 7348.19 united health care hmo adrenalin epinephrine inject cpt J0171 2087.31 2087.31 439.13 439.13 3485.48 3485.48 2904.57 2904.57 E 2087.31 2087.31 united health care ppo adrenalin epinephrine inject cpt J0171 2087.31 2087.31 439.13 439.13 3485.48 3485.48 2904.57 2904.57 E 2087.31 2087.31 united health care pos adrenalin epinephrine inject cpt J0171 2087.31 2087.31 439.13 439.13 3485.48 3485.48 2904.57 2904.57 E 2087.31 2087.31 united health care hmo adrenalin epinephrine inject cpt J0171 2087.31 2087.31 439.13 439.13 3485.48 3485.48 2904.57 2904.57 E 2087.31 2087.31 united health care epo adrenalin epinephrine inject cpt J0171 2087.31 2087.31 439.13 439.13 3485.48 3485.48 2904.57 2904.57 E 2087.31 2087.31 united health care hmo "X-ray of femur, minimum 2 views" cpt 73552 218.7 218.7 21.25 21.25 333.26 333.26 277.72 277.72 E 218.7 218.7 united health care ppo "X-ray of femur, minimum 2 views" cpt 73552 218.7 218.7 21.25 21.25 333.26 333.26 277.72 277.72 E 218.7 218.7 united health care pos "X-ray of femur, minimum 2 views" cpt 73552 218.7 218.7 21.25 21.25 333.26 333.26 277.72 277.72 E 218.7 218.7 united health care hmo "X-ray of femur, minimum 2 views" cpt 73552 218.7 218.7 21.25 21.25 333.26 333.26 277.72 277.72 E 218.7 218.7 united health care epo "X-ray of femur, minimum 2 views" cpt 73552 218.7 218.7 21.25 21.25 333.26 333.26 277.72 277.72 E 218.7 218.7 united health care hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 11663.48 11663.48 united health care ppo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 11663.48 11663.48 united health care pos Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 11663.48 11663.48 united health care hmo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 11663.48 11663.48 united health care epo Infusion of chemotherapy into a vein cpt 96415 11663.48 11663.48 1629.98 1629.98 20223.6 20223.6 16853 16853 O 11663.48 11663.48 united health care hmo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 12553.76 12553.76 united health care ppo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 12553.76 12553.76 united health care pos adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 12553.76 12553.76 united health care hmo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 12553.76 12553.76 united health care epo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 12553.76 12553.76 united health care hmo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 20798.67 20798.67 united health care ppo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 20798.67 20798.67 united health care pos cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 20798.67 20798.67 united health care hmo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 20798.67 20798.67 united health care epo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 20798.67 20798.67 united health care hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care ppo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care pos "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care epo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 7348.19 7348.19 united health care ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 7348.19 7348.19 united health care pos Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 7348.19 7348.19 united health care hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 7348.19 7348.19 united health care epo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 7348.19 7348.19 united health care hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 5454.5 5454.5 united health care ppo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 5454.5 5454.5 united health care pos Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 5454.5 5454.5 united health care hmo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 5454.5 5454.5 united health care epo Infusion of different chemotherapy drug or substance into a vein cpt 96411 7924.91 7924.91 938.77 938.77 19924.8 19924.8 16604 16604 O 5454.5 5454.5 united health care hmo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 16466.26 16466.26 united health care ppo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 16466.26 16466.26 united health care pos Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 16466.26 16466.26 united health care hmo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 16466.26 16466.26 united health care epo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 16466.26 16466.26 united health care hmo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 23111.69 23111.69 united health care ppo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 23111.69 23111.69 united health care pos succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 23111.69 23111.69 united health care hmo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 23111.69 23111.69 united health care epo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 23111.69 23111.69 united health care hmo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 10295.72 10295.72 united health care ppo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 10295.72 10295.72 united health care pos Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 10295.72 10295.72 united health care hmo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 10295.72 10295.72 united health care epo Infusion of chemotherapy into a vein using push technique cpt 96409 16191.52 16191.52 2537.15 2537.15 19304.16 19304.16 16086.8 16086.8 O 10295.72 10295.72 united health care hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 160.27 160.27 united health care ppo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 160.27 160.27 united health care pos "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 160.27 160.27 united health care hmo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 160.27 160.27 united health care epo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 160.27 160.27 united health care hmo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 674.85 674.85 united health care ppo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 674.85 674.85 united health care pos Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 674.85 674.85 united health care hmo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 674.85 674.85 united health care epo Injection of substance into spinal canal of upper or middle back using imaging guidance cpt 62321 1180.35 1180.35 544.86 544.86 2358.05 2358.05 1965.04 1965.04 O 674.85 674.85 united health care hmo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 13417.93 13417.93 united health care ppo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 13417.93 13417.93 united health care pos hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 13417.93 13417.93 united health care hmo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 13417.93 13417.93 united health care epo hydralazine hcl injection cpt J0360 13417.93 13417.93 3688.73 3688.73 26090.35 26090.35 21741.96 21741.96 O 13417.93 13417.93 united health care hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 25.58 25.58 384.14 384.14 320.12 320.12 E 240.09 240.09 united health care ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 25.58 25.58 384.14 384.14 320.12 320.12 E 240.09 240.09 united health care pos "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 25.58 25.58 384.14 384.14 320.12 320.12 E 240.09 240.09 united health care hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 25.58 25.58 384.14 384.14 320.12 320.12 E 240.09 240.09 united health care epo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 25.58 25.58 384.14 384.14 320.12 320.12 E 240.09 240.09 united health care hmo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 11802.59 11802.59 united health care ppo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 11802.59 11802.59 united health care pos complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 11802.59 11802.59 united health care hmo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 11802.59 11802.59 united health care epo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 11802.59 11802.59 united health care hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2772.2 2772.2 united health care ppo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2772.2 2772.2 united health care pos Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2772.2 2772.2 united health care hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2772.2 2772.2 united health care epo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 2772.2 2772.2 united health care hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 15419.2 15419.2 united health care ppo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 15419.2 15419.2 united health care pos Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 15419.2 15419.2 united health care hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 15419.2 15419.2 united health care epo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 15419.2 15419.2 united health care hmo hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 16793.03 16793.03 united health care ppo hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 16793.03 16793.03 united health care pos hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 16793.03 16793.03 united health care hmo hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 16793.03 16793.03 united health care epo hip and femur procedures except major joint with mcc ms-drg 480 21300.97 21300.97 16007.64 16007.64 86719.46 86719.46 72266.22 72266.22 I 16793.03 16793.03 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 6390.02 6390.02 united health care ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 6390.02 6390.02 united health care pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 6390.02 6390.02 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 6390.02 6390.02 united health care epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 6390.02 6390.02 732.02 732.02 13759.18 13759.18 11465.98 11465.98 O 6390.02 6390.02 united health care hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 240.09 240.09 united health care ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 240.09 240.09 united health care pos "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 240.09 240.09 united health care hmo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 240.09 240.09 united health care epo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 240.09 240.09 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 3792.31 3792.31 united health care ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 3792.31 3792.31 united health care pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 3792.31 3792.31 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 3792.31 3792.31 united health care epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 3792.31 3792.31 united health care hmo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care ppo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care pos "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care hmo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care epo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care hmo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 118.85 118.85 united health care ppo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 118.85 118.85 united health care pos "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 118.85 118.85 united health care hmo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 118.85 118.85 united health care epo "Troponin (protein) analysis, quantitative" cpt 84484 118.85 118.85 11.09 11.09 179.4 179.4 149.5 149.5 O 118.85 118.85 united health care hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 9805.54 9805.54 united health care ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 9805.54 9805.54 united health care pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 9805.54 9805.54 united health care hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 9805.54 9805.54 united health care epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 9805.54 9805.54 united health care hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 12121.4 12121.4 united health care ppo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 12121.4 12121.4 united health care pos cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 12121.4 12121.4 united health care hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 12121.4 12121.4 united health care epo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 12121.4 12121.4 united health care hmo cefepime hcl for injection cpt J0692 3786.73 3786.73 162.77 162.77 11648.23 11648.23 9706.86 9706.86 O 3786.73 3786.73 united health care ppo cefepime hcl for injection cpt J0692 3786.73 3786.73 162.77 162.77 11648.23 11648.23 9706.86 9706.86 O 3786.73 3786.73 united health care pos cefepime hcl for injection cpt J0692 3786.73 3786.73 162.77 162.77 11648.23 11648.23 9706.86 9706.86 O 3786.73 3786.73 united health care hmo cefepime hcl for injection cpt J0692 3786.73 3786.73 162.77 162.77 11648.23 11648.23 9706.86 9706.86 O 3786.73 3786.73 united health care epo cefepime hcl for injection cpt J0692 3786.73 3786.73 162.77 162.77 11648.23 11648.23 9706.86 9706.86 O 3786.73 3786.73 united health care hmo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2110.35 2110.35 united health care ppo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2110.35 2110.35 united health care pos ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2110.35 2110.35 united health care hmo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2110.35 2110.35 united health care epo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2110.35 2110.35 united health care hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3931.6 3931.6 united health care ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3931.6 3931.6 united health care pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3931.6 3931.6 united health care hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3931.6 3931.6 united health care epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 3931.6 3931.6 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 26702.62 26702.62 united health care ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 26702.62 26702.62 united health care pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 26702.62 26702.62 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 26702.62 26702.62 united health care epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 26702.62 26702.62 united health care hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 736.82 736.82 united health care ppo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 736.82 736.82 united health care pos Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 736.82 736.82 united health care hmo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 736.82 736.82 united health care epo Fetal non-stress test cpt 59025 1379.36 1379.36 65.61 65.61 1203.36 1203.36 1002.8 1002.8 O 736.82 736.82 united health care hmo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 4713.74 4713.74 united health care ppo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 4713.74 4713.74 united health care pos ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 4713.74 4713.74 united health care hmo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 4713.74 4713.74 united health care epo ceftriaxone sodium injection cpt J0696 4713.74 4713.74 162.77 162.77 2380 2380 1983.33 1983.33 O 4713.74 4713.74 united health care hmo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care ppo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care pos "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care hmo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care epo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care hmo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 398.27 398.27 united health care ppo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 398.27 398.27 united health care pos betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 398.27 398.27 united health care hmo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 398.27 398.27 united health care epo betamethasone acet&sod phosp cpt J0702 1079.07 1079.07 127.03 127.03 1680.08 1680.08 1400.07 1400.07 O 398.27 398.27 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 3514.38 3514.38 united health care ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 3514.38 3514.38 united health care pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 3514.38 3514.38 united health care hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 3514.38 3514.38 united health care epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 3514.38 3514.38 united health care hmo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 23111.69 23111.69 united health care ppo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 23111.69 23111.69 united health care pos ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 23111.69 23111.69 united health care hmo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 23111.69 23111.69 united health care epo ciprofloxacin iv cpt J0744 23111.69 23111.69 3185.06 3185.06 23933.76 23933.76 19944.8 19944.8 O 23111.69 23111.69 united health care hmo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 13137.87 13137.87 united health care ppo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 13137.87 13137.87 united health care pos Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 13137.87 13137.87 united health care hmo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 13137.87 13137.87 united health care epo Destruction or removal of ovary or pelvic growths using an endoscope cpt 58662 13137.87 13137.87 4158.06 4158.06 21020.59 21020.59 17517.16 17517.16 O 13137.87 13137.87 united health care hmo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 3450.24 3450.24 united health care ppo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 3450.24 3450.24 united health care pos prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 3450.24 3450.24 united health care hmo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 3450.24 3450.24 united health care epo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 3450.24 3450.24 united health care hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 3844.63 3844.63 united health care ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 3844.63 3844.63 united health care pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 3844.63 3844.63 united health care hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 3844.63 3844.63 united health care epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 3844.63 3844.63 united health care hmo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 232.89 232.89 united health care ppo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 232.89 232.89 united health care pos "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 232.89 232.89 united health care hmo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 232.89 232.89 united health care epo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 232.89 232.89 united health care hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1053.51 1053.51 united health care ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1053.51 1053.51 united health care pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1053.51 1053.51 united health care hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1053.51 1053.51 united health care epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 1053.51 1053.51 united health care hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 5612.54 5612.54 united health care ppo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 5612.54 5612.54 united health care pos denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 5612.54 5612.54 united health care hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 5612.54 5612.54 united health care epo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 5612.54 5612.54 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 2712.74 2712.74 united health care ppo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 2712.74 2712.74 united health care pos "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 2712.74 2712.74 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 2712.74 2712.74 united health care epo "Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion" cpt 96368 2712.74 2712.74 729.65 729.65 7933.61 7933.61 6611.34 6611.34 E 2712.74 2712.74 united health care hmo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 258.78 258.78 united health care ppo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 258.78 258.78 united health care pos "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 258.78 258.78 united health care hmo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 258.78 258.78 united health care epo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 258.78 258.78 united health care hmo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1477.69 1477.69 united health care ppo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1477.69 1477.69 united health care pos methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1477.69 1477.69 united health care hmo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1477.69 1477.69 united health care epo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 1477.69 1477.69 united health care hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 5454.5 5454.5 united health care ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 5454.5 5454.5 united health care pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 5454.5 5454.5 united health care hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 5454.5 5454.5 united health care epo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 5454.5 5454.5 united health care hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 E 654.29 654.29 united health care ppo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 E 654.29 654.29 united health care pos "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 E 654.29 654.29 united health care hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 E 654.29 654.29 united health care epo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 E 654.29 654.29 united health care hmo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 643.64 643.64 united health care ppo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 643.64 643.64 united health care pos dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 643.64 643.64 united health care hmo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 643.64 643.64 united health care epo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 643.64 643.64 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 9075.75 9075.75 united health care ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 9075.75 9075.75 united health care pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 9075.75 9075.75 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 9075.75 9075.75 united health care epo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 9075.75 9075.75 588.86 588.86 11626.8 11626.8 9689 9689 O 9075.75 9075.75 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2311.63 2311.63 united health care ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2311.63 2311.63 united health care pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2311.63 2311.63 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2311.63 2311.63 united health care epo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2311.63 2311.63 united health care hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 7348.19 7348.19 united health care ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 7348.19 7348.19 united health care pos dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 7348.19 7348.19 united health care hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 7348.19 7348.19 united health care epo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 7348.19 7348.19 united health care hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 221.81 221.81 united health care ppo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 221.81 221.81 united health care pos "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 221.81 221.81 united health care hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 221.81 221.81 united health care epo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 221.81 221.81 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 3914.61 3914.61 united health care ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 3914.61 3914.61 united health care pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 3914.61 3914.61 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 3914.61 3914.61 united health care epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 3914.61 3914.61 united health care hmo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 4307.49 4307.49 united health care ppo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 4307.49 4307.49 united health care pos hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 4307.49 4307.49 united health care hmo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 4307.49 4307.49 united health care epo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 4307.49 4307.49 united health care hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 17413.33 17413.33 united health care ppo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 17413.33 17413.33 united health care pos hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 17413.33 17413.33 united health care hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 17413.33 17413.33 united health care epo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 17413.33 17413.33 united health care hmo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 118.85 118.85 united health care ppo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 118.85 118.85 united health care pos "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 118.85 118.85 united health care hmo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 118.85 118.85 united health care epo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 118.85 118.85 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 2575.12 2575.12 united health care ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 2575.12 2575.12 united health care pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 2575.12 2575.12 united health care hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 2575.12 2575.12 united health care epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 2575.12 2575.12 united health care hmo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2880.39 2880.39 united health care ppo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2880.39 2880.39 united health care pos diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2880.39 2880.39 united health care hmo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2880.39 2880.39 united health care epo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 2880.39 2880.39 united health care hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 3931.6 3931.6 united health care ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 3931.6 3931.6 united health care pos Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 3931.6 3931.6 united health care hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 3931.6 3931.6 united health care epo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 3931.6 3931.6 united health care hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 9075.75 9075.75 united health care ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 9075.75 9075.75 united health care pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 9075.75 9075.75 united health care hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 9075.75 9075.75 united health care epo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 9075.75 9075.75 325.54 325.54 3045.7 3045.7 2538.08 2538.08 O 9075.75 9075.75 united health care hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 17916.14 17916.14 united health care ppo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 17916.14 17916.14 united health care pos diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 17916.14 17916.14 united health care hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 17916.14 17916.14 united health care epo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 17916.14 17916.14 united health care hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 3013.18 3013.18 united health care ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 3013.18 3013.18 united health care pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 3013.18 3013.18 united health care hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 3013.18 3013.18 united health care epo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 3013.18 3013.18 united health care hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1095.51 1095.51 united health care ppo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1095.51 1095.51 united health care pos "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1095.51 1095.51 united health care hmo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1095.51 1095.51 united health care epo "Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort" cpt 95806 1095.51 1095.51 60.64 60.64 1752.82 1752.82 1460.68 1460.68 O 1095.51 1095.51 united health care hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2967.25 2967.25 united health care ppo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2967.25 2967.25 united health care pos Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2967.25 2967.25 united health care hmo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2967.25 2967.25 united health care epo Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube cpt 95811 2967.25 2967.25 431.05 431.05 3990.23 3990.23 3325.19 3325.19 O 2967.25 2967.25 united health care hmo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 6390.02 6390.02 united health care ppo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 6390.02 6390.02 united health care pos Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 6390.02 6390.02 united health care hmo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 6390.02 6390.02 united health care epo Pulmonary service or operation cpt 94799 10624.49 10624.49 271.85 271.85 36530.58 36530.58 30442.15 30442.15 O 6390.02 6390.02 united health care hmo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 368.09 368.09 united health care ppo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 368.09 368.09 united health care pos inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 368.09 368.09 united health care hmo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 368.09 368.09 united health care epo inj filgrastim excl biosimil cpt J1442 13361.26 13361.26 368.09 368.09 6381.84 6381.84 5318.2 5318.2 O 368.09 368.09 united health care hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 1090.37 1090.37 united health care ppo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 1090.37 1090.37 united health care pos Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 1090.37 1090.37 united health care hmo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 1090.37 1090.37 united health care epo Measurement of lung diffusing capacity cpt 94729 1090.37 1090.37 171.01 171.01 1600.01 1600.01 1333.34 1333.34 O 1090.37 1090.37 united health care hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 1090.38 1090.38 united health care ppo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 1090.38 1090.38 united health care pos Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 1090.38 1090.38 united health care hmo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 1090.38 1090.38 united health care epo Determination of lung volumes using plethysmography cpt 94726 1090.38 1090.38 159.8 159.8 1600.01 1600.01 1333.34 1333.34 O 1090.38 1090.38 united health care hmo "Partial thickness skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children)" cpt 15120 11689.03 11689.03 2683.82 2683.82 19013.27 19013.27 15844.39 15844.39 O 11689.03 11689.03 united health care ppo "Partial thickness skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children)" cpt 15120 11689.03 11689.03 2683.82 2683.82 19013.27 19013.27 15844.39 15844.39 O 11689.03 11689.03 united health care pos "Partial thickness skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children)" cpt 15120 11689.03 11689.03 2683.82 2683.82 19013.27 19013.27 15844.39 15844.39 O 11689.03 11689.03 united health care hmo "Partial thickness skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children)" cpt 15120 11689.03 11689.03 2683.82 2683.82 19013.27 19013.27 15844.39 15844.39 O 11689.03 11689.03 united health care epo "Partial thickness skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children)" cpt 15120 11689.03 11689.03 2683.82 2683.82 19013.27 19013.27 15844.39 15844.39 O 11689.03 11689.03 united health care hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5454.5 5454.5 united health care ppo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5454.5 5454.5 united health care pos fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5454.5 5454.5 united health care hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5454.5 5454.5 united health care epo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 5454.5 5454.5 united health care hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 4691.13 4691.13 united health care ppo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 4691.13 4691.13 united health care pos Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 4691.13 4691.13 united health care hmo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 4691.13 4691.13 united health care epo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 4691.13 4691.13 678.84 678.84 2811.67 2811.67 2343.06 2343.06 O 4691.13 4691.13 united health care hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 6390.02 6390.02 united health care ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 6390.02 6390.02 united health care pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 6390.02 6390.02 united health care hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 6390.02 6390.02 united health care epo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 6390.02 6390.02 762.39 762.39 13269.26 13269.26 11057.72 11057.72 O 6390.02 6390.02 united health care hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1098.38 1098.38 united health care ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1098.38 1098.38 united health care pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1098.38 1098.38 united health care hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1098.38 1098.38 united health care epo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1098.38 1098.38 united health care hmo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 1090.38 1090.38 united health care ppo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 1090.38 1090.38 united health care pos "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 1090.38 1090.38 united health care hmo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 1090.38 1090.38 united health care epo "Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration" cpt 94060 1090.38 1090.38 203.44 203.44 1633.93 1633.93 1361.61 1361.61 O 1090.38 1090.38 united health care hmo "lower extremity and humerus procedures except hip, foot and femur without cc/mcc" ms-drg 494 33138.65 33138.65 7298.14 7298.14 52502.23 52502.23 43751.86 43751.86 I 33138.65 33138.65 united health care ppo "lower extremity and humerus procedures except hip, foot and femur without cc/mcc" ms-drg 494 33138.65 33138.65 7298.14 7298.14 52502.23 52502.23 43751.86 43751.86 I 33138.65 33138.65 united health care pos "lower extremity and humerus procedures except hip, foot and femur without cc/mcc" ms-drg 494 33138.65 33138.65 7298.14 7298.14 52502.23 52502.23 43751.86 43751.86 I 33138.65 33138.65 united health care hmo "lower extremity and humerus procedures except hip, foot and femur without cc/mcc" ms-drg 494 33138.65 33138.65 7298.14 7298.14 52502.23 52502.23 43751.86 43751.86 I 33138.65 33138.65 united health care epo "lower extremity and humerus procedures except hip, foot and femur without cc/mcc" ms-drg 494 33138.65 33138.65 7298.14 7298.14 52502.23 52502.23 43751.86 43751.86 I 33138.65 33138.65 united health care hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 181.26 181.26 united health care ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 181.26 181.26 united health care pos "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 181.26 181.26 united health care hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 181.26 181.26 united health care epo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 181.26 181.26 united health care hmo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 73.37 73.37 united health care ppo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 73.37 73.37 united health care pos "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 73.37 73.37 united health care hmo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 73.37 73.37 united health care epo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 73.37 73.37 united health care hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 515.96 515.96 united health care ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 515.96 515.96 united health care pos Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 515.96 515.96 united health care hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 515.96 515.96 united health care epo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 515.96 515.96 united health care hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care pos inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care epo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 137.73 137.73 united health care hmo "X-ray of abdomen, minimum of 3 views" cpt 74021 260.76 260.76 22.27 22.27 417.22 417.22 347.68 347.68 E 260.76 260.76 united health care ppo "X-ray of abdomen, minimum of 3 views" cpt 74021 260.76 260.76 22.27 22.27 417.22 417.22 347.68 347.68 E 260.76 260.76 united health care pos "X-ray of abdomen, minimum of 3 views" cpt 74021 260.76 260.76 22.27 22.27 417.22 417.22 347.68 347.68 E 260.76 260.76 united health care hmo "X-ray of abdomen, minimum of 3 views" cpt 74021 260.76 260.76 22.27 22.27 417.22 417.22 347.68 347.68 E 260.76 260.76 united health care epo "X-ray of abdomen, minimum of 3 views" cpt 74021 260.76 260.76 22.27 22.27 417.22 417.22 347.68 347.68 E 260.76 260.76 united health care hmo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 23096.99 23096.99 united health care ppo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 23096.99 23096.99 united health care pos inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 23096.99 23096.99 united health care hmo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 23096.99 23096.99 united health care epo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 23096.99 23096.99 united health care hmo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 16160.85 16160.85 united health care ppo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 16160.85 16160.85 united health care pos inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 16160.85 16160.85 united health care hmo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 16160.85 16160.85 united health care epo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 16160.85 16160.85 united health care hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 685.6 685.6 united health care ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 685.6 685.6 united health care pos Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 685.6 685.6 united health care hmo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 685.6 685.6 united health care epo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 685.6 685.6 united health care hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 6677.69 6677.69 united health care ppo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 6677.69 6677.69 united health care pos inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 6677.69 6677.69 united health care hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 6677.69 6677.69 united health care epo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 6677.69 6677.69 united health care hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 773.81 773.81 united health care ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 773.81 773.81 united health care pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 773.81 773.81 united health care hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 773.81 773.81 united health care epo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 773.81 773.81 united health care hmo Ultrasound study of arteries and arterial grafts of one arm or limited cpt 93931 431.57 431.57 97.7 97.7 657.62 657.62 548.02 548.02 O 431.57 431.57 united health care ppo Ultrasound study of arteries and arterial grafts of one arm or limited cpt 93931 431.57 431.57 97.7 97.7 657.62 657.62 548.02 548.02 O 431.57 431.57 united health care pos Ultrasound study of arteries and arterial grafts of one arm or limited cpt 93931 431.57 431.57 97.7 97.7 657.62 657.62 548.02 548.02 O 431.57 431.57 united health care hmo Ultrasound study of arteries and arterial grafts of one arm or limited cpt 93931 431.57 431.57 97.7 97.7 657.62 657.62 548.02 548.02 O 431.57 431.57 united health care epo Ultrasound study of arteries and arterial grafts of one arm or limited cpt 93931 431.57 431.57 97.7 97.7 657.62 657.62 548.02 548.02 O 431.57 431.57 united health care hmo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 E 349.8 349.8 united health care ppo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 E 349.8 349.8 united health care pos Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 E 349.8 349.8 united health care hmo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 E 349.8 349.8 united health care epo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 E 349.8 349.8 united health care hmo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 4691.13 4691.13 united health care ppo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 4691.13 4691.13 united health care pos inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 4691.13 4691.13 united health care hmo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 4691.13 4691.13 united health care epo inj enoxaparin sodium cpt J1650 7453.01 7453.01 2904.35 2904.35 27768.92 27768.92 23140.77 23140.77 O 4691.13 4691.13 united health care hmo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 349.8 349.8 united health care ppo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 349.8 349.8 united health care pos Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 349.8 349.8 united health care hmo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 349.8 349.8 united health care epo Complete X-ray study of abdomen with single X-ray of chest cpt 74022 349.8 349.8 25.58 25.58 559.68 559.68 466.4 466.4 O 349.8 349.8 united health care hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 411.02 411.02 united health care ppo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 411.02 411.02 united health care pos Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 411.02 411.02 united health care hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 411.02 411.02 united health care epo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.02 411.02 93.85 93.85 657.62 657.62 548.02 548.02 O 411.02 411.02 united health care hmo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1476.71 1476.71 united health care ppo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1476.71 1476.71 united health care pos ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1476.71 1476.71 united health care hmo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1476.71 1476.71 united health care epo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 1476.71 1476.71 united health care hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 411.01 411.01 united health care ppo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 411.01 411.01 united health care pos Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 411.01 411.01 united health care hmo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 411.01 411.01 united health care epo Ultrasound study of arteries and arterial grafts of one leg or limited cpt 93926 411.01 411.01 93.1 93.1 690.5 690.5 575.42 575.42 E 411.01 411.01 united health care hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 3855.93 3855.93 united health care ppo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 3855.93 3855.93 united health care pos ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 3855.93 3855.93 united health care hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 3855.93 3855.93 united health care epo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 3855.93 3855.93 united health care hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care ppo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care pos "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care epo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 479.39 479.39 united health care ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 479.39 479.39 united health care pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 479.39 479.39 united health care hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 479.39 479.39 united health care epo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 479.39 479.39 united health care hmo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1563.96 1563.96 united health care ppo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1563.96 1563.96 united health care pos furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1563.96 1563.96 united health care hmo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1563.96 1563.96 united health care epo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1563.96 1563.96 united health care hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 3786.73 3786.73 united health care ppo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 3786.73 3786.73 united health care pos furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 3786.73 3786.73 united health care hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 3786.73 3786.73 united health care epo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 3786.73 3786.73 united health care hmo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 1118.22 1118.22 united health care ppo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 1118.22 1118.22 united health care pos CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 1118.22 1118.22 united health care hmo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 1118.22 1118.22 united health care epo CT scan abdomen with contrast cpt 74160 1118.22 1118.22 147.45 147.45 2148.41 2148.41 1790.34 1790.34 O 1118.22 1118.22 united health care hmo leuprolide acetate /3.75 mg cpt J1950 2839.81 2839.81 2839.81 2839.81 4327.34 4327.34 3606.12 3606.12 O 2839.81 2839.81 united health care ppo leuprolide acetate /3.75 mg cpt J1950 2839.81 2839.81 2839.81 2839.81 4327.34 4327.34 3606.12 3606.12 O 2839.81 2839.81 united health care pos leuprolide acetate /3.75 mg cpt J1950 2839.81 2839.81 2839.81 2839.81 4327.34 4327.34 3606.12 3606.12 O 2839.81 2839.81 united health care hmo leuprolide acetate /3.75 mg cpt J1950 2839.81 2839.81 2839.81 2839.81 4327.34 4327.34 3606.12 3606.12 O 2839.81 2839.81 united health care epo leuprolide acetate /3.75 mg cpt J1950 2839.81 2839.81 2839.81 2839.81 4327.34 4327.34 3606.12 3606.12 O 2839.81 2839.81 united health care hmo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 3173.26 3173.26 united health care ppo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 3173.26 3173.26 united health care pos levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 3173.26 3173.26 united health care hmo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 3173.26 3173.26 united health care epo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 3173.26 3173.26 united health care hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 503.35 503.35 united health care ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 503.35 503.35 united health care pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 503.35 503.35 united health care hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 503.35 503.35 united health care epo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 503.35 503.35 90 90 767.02 767.02 639.18 639.18 E 503.35 503.35 united health care hmo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1708.46 1708.46 united health care ppo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1708.46 1708.46 united health care pos CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1708.46 1708.46 united health care hmo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1708.46 1708.46 united health care epo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 1708.46 1708.46 united health care hmo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 6110.48 6110.48 united health care ppo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 6110.48 6110.48 united health care pos "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 6110.48 6110.48 united health care hmo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 6110.48 6110.48 united health care epo "Needle biopsy of kidney, accessed through the skin" cpt 50200 6110.48 6110.48 1116.61 1116.61 9226.97 9226.97 7689.14 7689.14 O 6110.48 6110.48 united health care hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1708.45 1708.45 united health care ppo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1708.45 1708.45 united health care pos CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1708.45 1708.45 united health care hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1708.45 1708.45 united health care epo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1708.45 1708.45 united health care hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 16100.16 16100.16 united health care ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 16100.16 16100.16 united health care pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 16100.16 16100.16 united health care hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 16100.16 16100.16 united health care epo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 16100.16 16100.16 united health care hmo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 3662.54 3662.54 united health care ppo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 3662.54 3662.54 united health care pos lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 3662.54 3662.54 united health care hmo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 3662.54 3662.54 united health care epo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 3662.54 3662.54 united health care hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 19046.96 19046.96 united health care ppo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 19046.96 19046.96 united health care pos Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 19046.96 19046.96 united health care hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 19046.96 19046.96 united health care epo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 19046.96 19046.96 united health care hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 23096.99 23096.99 united health care ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 23096.99 23096.99 united health care pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 23096.99 23096.99 united health care hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 23096.99 23096.99 united health care epo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 23096.99 23096.99 1461.03 1461.03 44986.61 44986.61 37488.84 37488.84 E 23096.99 23096.99 united health care hmo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 10827.93 10827.93 united health care ppo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 10827.93 10827.93 united health care pos mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 10827.93 10827.93 united health care hmo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 10827.93 10827.93 united health care epo mannitol injection cpt J2150 10827.93 10827.93 832.09 832.09 26665.03 26665.03 22220.86 22220.86 O 10827.93 10827.93 united health care hmo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 279.84 279.84 united health care ppo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 279.84 279.84 united health care pos Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 279.84 279.84 united health care hmo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 279.84 279.84 united health care epo Follow-up or limited ultrasound examination of heart cpt 93308 279.84 279.84 188.57 188.57 447.74 447.74 373.12 373.12 O 279.84 279.84 united health care hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1269.62 1269.62 united health care ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1269.62 1269.62 united health care pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1269.62 1269.62 united health care hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1269.62 1269.62 united health care epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1269.62 1269.62 united health care hmo inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 23096.99 23096.99 united health care ppo inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 23096.99 23096.99 united health care pos inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 23096.99 23096.99 united health care hmo inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 23096.99 23096.99 united health care epo inj midazolam hydrochloride cpt J2250 23096.99 23096.99 2179.77 2179.77 32244.66 32244.66 26870.55 26870.55 E 23096.99 23096.99 united health care hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 6073.23 6073.23 united health care ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 6073.23 6073.23 united health care pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 6073.23 6073.23 united health care hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 6073.23 6073.23 united health care epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 6073.23 6073.23 united health care hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 15146.83 15146.83 united health care ppo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 15146.83 15146.83 united health care pos inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 15146.83 15146.83 united health care hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 15146.83 15146.83 united health care epo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 15146.83 15146.83 united health care hmo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care ppo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care pos Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care hmo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care epo Blood glucose (sugar) level after receiving dose of glucose cpt 82950 26.24 26.24 4.23 4.23 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care hmo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 215.45 215.45 united health care ppo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 215.45 215.45 united health care pos "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 215.45 215.45 united health care hmo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 215.45 215.45 united health care epo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 215.45 215.45 united health care hmo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 3792.31 3792.31 united health care ppo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 3792.31 3792.31 united health care pos morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 3792.31 3792.31 united health care hmo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 3792.31 3792.31 united health care epo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 3792.31 3792.31 united health care hmo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 116.07 116.07 united health care ppo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 116.07 116.07 united health care pos Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 116.07 116.07 united health care hmo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 116.07 116.07 united health care epo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 116.07 116.07 united health care hmo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care ppo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care pos "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care hmo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care epo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 6865.24 6865.24 united health care ppo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 6865.24 6865.24 united health care pos morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 6865.24 6865.24 united health care hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 6865.24 6865.24 united health care epo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 6865.24 6865.24 united health care hmo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care ppo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care pos "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care hmo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care epo "Heart rhythm analysis, interpretation and report of 48-hour EKG" cpt 93226 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care hmo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care ppo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care pos Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care hmo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care epo Heart rhythm tracing of 48-hour EKG cpt 93225 355.6 355.6 52.96 52.96 541.87 541.87 451.56 451.56 O 355.6 355.6 united health care hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 5285.79 5285.79 united health care ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 5285.79 5285.79 united health care pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 5285.79 5285.79 united health care hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 5285.79 5285.79 united health care epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 5285.79 5285.79 united health care hmo "octreotide inj, non-depot" cpt J2354 6865.24 6865.24 1357.6 1357.6 10984.32 10984.32 9153.6 9153.6 O 6865.24 6865.24 united health care ppo "octreotide inj, non-depot" cpt J2354 6865.24 6865.24 1357.6 1357.6 10984.32 10984.32 9153.6 9153.6 O 6865.24 6865.24 united health care pos "octreotide inj, non-depot" cpt J2354 6865.24 6865.24 1357.6 1357.6 10984.32 10984.32 9153.6 9153.6 O 6865.24 6865.24 united health care hmo "octreotide inj, non-depot" cpt J2354 6865.24 6865.24 1357.6 1357.6 10984.32 10984.32 9153.6 9153.6 O 6865.24 6865.24 united health care epo "octreotide inj, non-depot" cpt J2354 6865.24 6865.24 1357.6 1357.6 10984.32 10984.32 9153.6 9153.6 O 6865.24 6865.24 united health care hmo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1538.8 1538.8 united health care ppo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1538.8 1538.8 united health care pos Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1538.8 1538.8 united health care hmo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1538.8 1538.8 united health care epo Drainage of fluid from abdominal cavity using imaging guidance cpt 49083 1538.8 1538.8 659.31 659.31 2626.91 2626.91 2189.09 2189.09 O 1538.8 1538.8 united health care hmo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 716.17 716.17 united health care ppo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 716.17 716.17 united health care pos orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 716.17 716.17 united health care hmo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 716.17 716.17 united health care epo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 716.17 716.17 united health care hmo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 326.14 326.14 united health care ppo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 326.14 326.14 united health care pos X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 326.14 326.14 united health care hmo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 326.14 326.14 united health care epo X-ray of upper digestive tract with single contrast cpt 74240 326.14 326.14 73.98 73.98 521.82 521.82 434.85 434.85 O 326.14 326.14 united health care hmo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 875.18 875.18 united health care ppo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 875.18 875.18 united health care pos CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 875.18 875.18 united health care hmo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 875.18 875.18 united health care epo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 875.18 875.18 united health care hmo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 30.13 30.13 united health care ppo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 30.13 30.13 united health care pos Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 30.13 30.13 united health care hmo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 30.13 30.13 united health care epo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 30.13 30.13 united health care hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 23111.69 23111.69 united health care ppo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 23111.69 23111.69 united health care pos phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 23111.69 23111.69 united health care hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 23111.69 23111.69 united health care epo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 23111.69 23111.69 united health care hmo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 16237.85 16237.85 united health care ppo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 16237.85 16237.85 united health care pos Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 16237.85 16237.85 united health care hmo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 16237.85 16237.85 united health care epo Removal of gallbladder with X-ray study of bile ducts using endoscope cpt 47563 16237.85 16237.85 3942.46 3942.46 25980.56 25980.56 21650.47 21650.47 O 16237.85 16237.85 united health care hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 10082.72 10082.72 united health care ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 10082.72 10082.72 united health care pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 10082.72 10082.72 united health care hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 10082.72 10082.72 united health care epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 10082.72 10082.72 united health care hmo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 3972.76 3972.76 united health care ppo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 3972.76 3972.76 united health care pos ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 3972.76 3972.76 united health care hmo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 3972.76 3972.76 united health care epo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 3972.76 3972.76 united health care hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 5389.93 5389.93 united health care ppo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 5389.93 5389.93 united health care pos ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 5389.93 5389.93 united health care hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 5389.93 5389.93 united health care epo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 5389.93 5389.93 united health care hmo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 326.2 326.2 united health care ppo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 326.2 326.2 united health care pos X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 326.2 326.2 united health care hmo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 326.2 326.2 united health care epo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 326.2 326.2 united health care hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.66 11.66 united health care ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.66 11.66 united health care pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.66 11.66 united health care hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.66 11.66 united health care epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 11.66 11.66 united health care hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 9805.54 9805.54 united health care ppo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 9805.54 9805.54 united health care pos palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 9805.54 9805.54 united health care hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 9805.54 9805.54 united health care epo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 9805.54 9805.54 united health care hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1195.52 1195.52 united health care ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1195.52 1195.52 united health care pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1195.52 1195.52 united health care hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1195.52 1195.52 united health care epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1195.52 1195.52 united health care hmo Tying of multiple internal hemorrhoid groups cpt 46946 17972.06 17972.06 2076.66 2076.66 15925.92 15925.92 13271.6 13271.6 O 17972.06 17972.06 united health care ppo Tying of multiple internal hemorrhoid groups cpt 46946 17972.06 17972.06 2076.66 2076.66 15925.92 15925.92 13271.6 13271.6 O 17972.06 17972.06 united health care pos Tying of multiple internal hemorrhoid groups cpt 46946 17972.06 17972.06 2076.66 2076.66 15925.92 15925.92 13271.6 13271.6 O 17972.06 17972.06 united health care hmo Tying of multiple internal hemorrhoid groups cpt 46946 17972.06 17972.06 2076.66 2076.66 15925.92 15925.92 13271.6 13271.6 O 17972.06 17972.06 united health care epo Tying of multiple internal hemorrhoid groups cpt 46946 17972.06 17972.06 2076.66 2076.66 15925.92 15925.92 13271.6 13271.6 O 17972.06 17972.06 united health care hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 2181.77 2181.77 united health care ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 2181.77 2181.77 united health care pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 2181.77 2181.77 united health care hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 2181.77 2181.77 united health care epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 2181.77 2181.77 united health care hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 10344.21 10344.21 united health care ppo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 10344.21 10344.21 united health care pos "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 10344.21 10344.21 united health care hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 10344.21 10344.21 united health care epo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 10344.21 10344.21 united health care hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 430.09 430.09 united health care ppo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 430.09 430.09 united health care pos "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 430.09 430.09 united health care hmo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 430.09 430.09 united health care epo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 430.09 430.09 united health care hmo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 13430.9 13430.9 united health care ppo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 13430.9 13430.9 united health care pos neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 13430.9 13430.9 united health care hmo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 13430.9 13430.9 united health care epo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 13430.9 13430.9 united health care hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 331.52 331.52 united health care ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 331.52 331.52 united health care pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 331.52 331.52 united health care hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 331.52 331.52 united health care epo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 331.52 331.52 united health care hmo "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 6390.02 6390.02 united health care ppo "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 6390.02 6390.02 united health care pos "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 6390.02 6390.02 united health care hmo "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 6390.02 6390.02 united health care epo "Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free" cpt 90686 11116.59 11116.59 50.63 50.63 721.56 721.56 601.3 601.3 O 6390.02 6390.02 united health care hmo Vaccine for rabies injection into skin cpt 90676 4295.94 4295.94 229.65 229.65 1669.33 1669.33 1391.11 1391.11 E 4295.94 4295.94 united health care ppo Vaccine for rabies injection into skin cpt 90676 4295.94 4295.94 229.65 229.65 1669.33 1669.33 1391.11 1391.11 E 4295.94 4295.94 united health care pos Vaccine for rabies injection into skin cpt 90676 4295.94 4295.94 229.65 229.65 1669.33 1669.33 1391.11 1391.11 E 4295.94 4295.94 united health care hmo Vaccine for rabies injection into skin cpt 90676 4295.94 4295.94 229.65 229.65 1669.33 1669.33 1391.11 1391.11 E 4295.94 4295.94 united health care epo Vaccine for rabies injection into skin cpt 90676 4295.94 4295.94 229.65 229.65 1669.33 1669.33 1391.11 1391.11 E 4295.94 4295.94 united health care hmo Administration of vaccine cpt 90472 4295.94 4295.94 368.14 368.14 10250.63 10250.63 8542.19 8542.19 E 4295.94 4295.94 united health care ppo Administration of vaccine cpt 90472 4295.94 4295.94 368.14 368.14 10250.63 10250.63 8542.19 8542.19 E 4295.94 4295.94 united health care pos Administration of vaccine cpt 90472 4295.94 4295.94 368.14 368.14 10250.63 10250.63 8542.19 8542.19 E 4295.94 4295.94 united health care hmo Administration of vaccine cpt 90472 4295.94 4295.94 368.14 368.14 10250.63 10250.63 8542.19 8542.19 E 4295.94 4295.94 united health care epo Administration of vaccine cpt 90472 4295.94 4295.94 368.14 368.14 10250.63 10250.63 8542.19 8542.19 E 4295.94 4295.94 united health care hmo metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 3972.76 3972.76 united health care ppo metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 3972.76 3972.76 united health care pos metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 3972.76 3972.76 united health care hmo metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 3972.76 3972.76 united health care epo metoclopramide hcl injection cpt J2765 21270.9 21270.9 544.16 544.16 4067.09 4067.09 3389.24 3389.24 E 3972.76 3972.76 united health care hmo Removal of external hemorrhoids by rubber banding cpt 46221 17972.06 17972.06 676.71 676.71 5123.33 5123.33 4269.44 4269.44 O 17972.06 17972.06 united health care ppo Removal of external hemorrhoids by rubber banding cpt 46221 17972.06 17972.06 676.71 676.71 5123.33 5123.33 4269.44 4269.44 O 17972.06 17972.06 united health care pos Removal of external hemorrhoids by rubber banding cpt 46221 17972.06 17972.06 676.71 676.71 5123.33 5123.33 4269.44 4269.44 O 17972.06 17972.06 united health care hmo Removal of external hemorrhoids by rubber banding cpt 46221 17972.06 17972.06 676.71 676.71 5123.33 5123.33 4269.44 4269.44 O 17972.06 17972.06 united health care epo Removal of external hemorrhoids by rubber banding cpt 46221 17972.06 17972.06 676.71 676.71 5123.33 5123.33 4269.44 4269.44 O 17972.06 17972.06 united health care hmo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 722.18 722.18 united health care ppo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 722.18 722.18 united health care pos Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 722.18 722.18 united health care hmo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 722.18 722.18 united health care epo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 722.18 722.18 united health care hmo Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 733.62 733.62 united health care ppo Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 733.62 733.62 united health care pos Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 733.62 733.62 united health care hmo Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 733.62 733.62 united health care epo Incision of external hemorrhoid with blood clot (thrombosed hemorrhoid) cpt 46083 733.62 733.62 405.94 405.94 1173.78 1173.78 978.15 978.15 E 733.62 733.62 united health care hmo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 10082.72 10082.72 united health care ppo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 10082.72 10082.72 united health care pos regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 10082.72 10082.72 united health care hmo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 10082.72 10082.72 united health care epo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 10082.72 10082.72 united health care hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 5481.82 5481.82 united health care ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 5481.82 5481.82 united health care pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 5481.82 5481.82 united health care hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 5481.82 5481.82 united health care epo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 5481.82 5481.82 united health care hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 205.91 205.91 united health care ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 205.91 205.91 united health care pos "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 205.91 205.91 united health care hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 205.91 205.91 united health care epo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 205.91 205.91 united health care hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 35.45 35.45 united health care ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 35.45 35.45 united health care pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 35.45 35.45 united health care hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 35.45 35.45 united health care epo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 35.45 35.45 united health care hmo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 283.02 283.02 united health care ppo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 283.02 283.02 united health care pos "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 283.02 283.02 united health care hmo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 283.02 283.02 united health care epo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 283.02 283.02 united health care hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 478.59 478.59 united health care ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 478.59 478.59 united health care pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 478.59 478.59 united health care hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 478.59 478.59 united health care epo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 E 478.59 478.59 united health care hmo "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 80.93 80.93 united health care ppo "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 80.93 80.93 united health care pos "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 80.93 80.93 united health care hmo "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 80.93 80.93 united health care epo "Thyroxine (thyroid chemical), free" cpt 84439 107.9 107.9 8.02 8.02 129.48 129.48 107.9 107.9 E 80.93 80.93 united health care hmo methylprednisolone injection cpt J2920 8072.2 8072.2 5421.18 5421.18 15330.14 15330.14 12775.12 12775.12 O 5540.58 5540.58 united health care ppo methylprednisolone injection cpt J2920 8072.2 8072.2 5421.18 5421.18 15330.14 15330.14 12775.12 12775.12 O 5540.58 5540.58 united health care pos methylprednisolone injection cpt J2920 8072.2 8072.2 5421.18 5421.18 15330.14 15330.14 12775.12 12775.12 O 5540.58 5540.58 united health care hmo methylprednisolone injection cpt J2920 8072.2 8072.2 5421.18 5421.18 15330.14 15330.14 12775.12 12775.12 O 5540.58 5540.58 united health care epo methylprednisolone injection cpt J2920 8072.2 8072.2 5421.18 5421.18 15330.14 15330.14 12775.12 12775.12 O 5540.58 5540.58 united health care hmo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 2087.31 2087.31 united health care ppo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 2087.31 2087.31 united health care pos methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 2087.31 2087.31 united health care hmo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 2087.31 2087.31 united health care epo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 2087.31 2087.31 united health care hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 478.59 478.59 united health care ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 478.59 478.59 united health care pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 478.59 478.59 united health care hmo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 478.59 478.59 united health care epo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 478.59 478.59 united health care hmo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 170.13 170.13 united health care ppo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 170.13 170.13 united health care pos "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 170.13 170.13 united health care hmo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 170.13 170.13 united health care epo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 170.13 170.13 united health care hmo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 3426.89 3426.89 united health care ppo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 3426.89 3426.89 united health care pos methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 3426.89 3426.89 united health care hmo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 3426.89 3426.89 united health care epo methylprednisolone injection cpt J2930 4388.57 4388.57 196.53 196.53 5089.15 5089.15 4240.96 4240.96 O 3426.89 3426.89 united health care hmo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 57.24 57.24 united health care ppo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 57.24 57.24 united health care pos Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 57.24 57.24 united health care hmo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 57.24 57.24 united health care epo Hemoglobin A1C level cpt 83036 57.24 57.24 8.64 8.64 91.58 91.58 76.32 76.32 E 57.24 57.24 united health care hmo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 8558.99 8558.99 united health care ppo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 8558.99 8558.99 united health care pos alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 8558.99 8558.99 united health care hmo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 8558.99 8558.99 united health care epo alteplase recombinant cpt J2997 14238.66 14238.66 2009.92 2009.92 23969.68 23969.68 19974.73 19974.73 O 8558.99 8558.99 united health care hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 143.1 143.1 united health care ppo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 143.1 143.1 united health care pos "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 143.1 143.1 united health care hmo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 143.1 143.1 united health care epo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 143.1 143.1 united health care hmo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 4010.86 4010.86 united health care ppo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 4010.86 4010.86 united health care pos fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 4010.86 4010.86 united health care hmo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 4010.86 4010.86 united health care epo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 4010.86 4010.86 united health care hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 12553.76 12553.76 united health care ppo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 12553.76 12553.76 united health care pos fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 12553.76 12553.76 united health care hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 12553.76 12553.76 united health care epo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 12553.76 12553.76 united health care hmo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 33.39 33.39 united health care ppo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 33.39 33.39 united health care pos "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 33.39 33.39 united health care hmo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 33.39 33.39 united health care epo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 33.39 33.39 united health care hmo Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 23111.69 23111.69 united health care ppo Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 23111.69 23111.69 united health care pos Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 23111.69 23111.69 united health care hmo Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 23111.69 23111.69 united health care epo Repair of muscle at esophagus and stomach using an endoscope cpt 43280 23111.69 23111.69 6846.83 6846.83 37921.39 37921.39 31601.16 31601.16 O 23111.69 23111.69 united health care hmo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 275.47 275.47 united health care ppo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 275.47 275.47 united health care pos "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 275.47 275.47 united health care hmo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 275.47 275.47 united health care epo "Ultrasound behind abdominal cavity, limited" cpt 76775 275.47 275.47 99.29 99.29 419.76 419.76 349.8 349.8 O 275.47 275.47 united health care hmo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care ppo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care pos Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care hmo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care epo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care hmo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 968.91 968.91 united health care ppo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 968.91 968.91 united health care pos "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 968.91 968.91 united health care hmo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 968.91 968.91 united health care epo "Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12004 968.91 968.91 300.35 300.35 1868.68 1868.68 1557.23 1557.23 E 968.91 968.91 united health care hmo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 40.46 40.46 united health care ppo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 40.46 40.46 united health care pos "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 40.46 40.46 united health care hmo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 40.46 40.46 united health care epo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 40.46 40.46 united health care hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 255.2 255.2 61.35 61.35 408.31 408.31 340.26 340.26 E 255.2 255.2 united health care ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 255.2 255.2 61.35 61.35 408.31 408.31 340.26 340.26 E 255.2 255.2 united health care pos Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 255.2 255.2 61.35 61.35 408.31 408.31 340.26 340.26 E 255.2 255.2 united health care hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 255.2 255.2 61.35 61.35 408.31 408.31 340.26 340.26 E 255.2 255.2 united health care epo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 255.2 255.2 61.35 61.35 408.31 408.31 340.26 340.26 E 255.2 255.2 united health care hmo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 7750.85 7750.85 united health care ppo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 7750.85 7750.85 united health care pos vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 7750.85 7750.85 united health care hmo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 7750.85 7750.85 united health care epo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 7750.85 7750.85 united health care hmo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 280.64 280.64 united health care ppo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 280.64 280.64 united health care pos Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 280.64 280.64 united health care hmo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 280.64 280.64 united health care epo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 280.64 280.64 united health care hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 65.52 65.52 united health care ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 65.52 65.52 united health care pos "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 65.52 65.52 united health care hmo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 65.52 65.52 united health care epo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 65.52 65.52 united health care hmo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 13407.23 13407.23 united health care ppo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 13407.23 13407.23 united health care pos cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 13407.23 13407.23 united health care hmo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 13407.23 13407.23 united health care epo cellulitis without mcc ms-drg 603 13407.23 13407.23 3088.85 3088.85 23262.28 23262.28 19385.23 19385.23 I 13407.23 13407.23 united health care hmo thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 3628.75 3628.75 united health care ppo thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 3628.75 3628.75 united health care pos thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 3628.75 3628.75 united health care hmo thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 3628.75 3628.75 united health care epo thiamine hcl 100 mg cpt J3411 3628.75 3628.75 508.17 508.17 5986.43 5986.43 4988.69 4988.69 E 3628.75 3628.75 united health care hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 80.97 80.97 united health care ppo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 80.97 80.97 united health care pos "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 80.97 80.97 united health care hmo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 80.97 80.97 united health care epo "Blood glucose (sugar) tolerance test, 3 specimens" cpt 82951 80.97 80.97 11.45 11.45 126.82 126.82 105.68 105.68 O 80.97 80.97 united health care hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 255.2 255.2 united health care ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 255.2 255.2 united health care pos Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 255.2 255.2 united health care hmo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 255.2 255.2 united health care epo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 255.2 255.2 united health care hmo inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 6677.69 6677.69 united health care ppo inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 6677.69 6677.69 united health care pos inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 6677.69 6677.69 united health care hmo inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 6677.69 6677.69 united health care epo inj magnesium sulfate cpt J3475 6677.69 6677.69 796.68 796.68 11780.23 11780.23 9816.86 9816.86 E 6677.69 6677.69 united health care hmo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care ppo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care pos "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care epo "Ultrasound of pregnant uterus, 1 or more fetus(es)" cpt 76815 411.81 411.81 84.57 84.57 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 701.13 701.13 344.09 344.09 1121.8 1121.8 934.83 934.83 E 701.13 701.13 united health care ppo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 701.13 701.13 344.09 344.09 1121.8 1121.8 934.83 934.83 E 701.13 701.13 united health care pos "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 701.13 701.13 344.09 344.09 1121.8 1121.8 934.83 934.83 E 701.13 701.13 united health care hmo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 701.13 701.13 344.09 344.09 1121.8 1121.8 934.83 934.83 E 701.13 701.13 united health care epo "Drainage of abscess, cyst, or blood accumulation of dental bone" cpt 41800 701.13 701.13 344.09 344.09 1121.8 1121.8 934.83 934.83 E 701.13 701.13 united health care hmo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 10827.93 10827.93 united health care ppo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 10827.93 10827.93 united health care pos inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 10827.93 10827.93 united health care hmo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 10827.93 10827.93 united health care epo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 10827.93 10827.93 united health care hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 77.12 77.12 united health care ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 77.12 77.12 united health care pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 77.12 77.12 united health care hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 77.12 77.12 united health care epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 77.12 77.12 united health care hmo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 10827.93 10827.93 united health care ppo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 10827.93 10827.93 united health care pos inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 10827.93 10827.93 united health care hmo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 10827.93 10827.93 united health care epo inj potassium chloride cpt J3480 10827.93 10827.93 832.09 832.09 17141.53 17141.53 14284.61 14284.61 O 10827.93 10827.93 united health care hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 77.12 77.12 united health care ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 77.12 77.12 united health care pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 77.12 77.12 united health care hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 77.12 77.12 united health care epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 17.83 17.83 123.38 123.38 102.82 102.82 E 77.12 77.12 united health care hmo "Stool analysis for blood, by peroxidase activity" cpt 82272 16.86 16.86 3.76 3.76 25.69 25.69 21.41 21.41 E 16.86 16.86 united health care ppo "Stool analysis for blood, by peroxidase activity" cpt 82272 16.86 16.86 3.76 3.76 25.69 25.69 21.41 21.41 E 16.86 16.86 united health care pos "Stool analysis for blood, by peroxidase activity" cpt 82272 16.86 16.86 3.76 3.76 25.69 25.69 21.41 21.41 E 16.86 16.86 united health care hmo "Stool analysis for blood, by peroxidase activity" cpt 82272 16.86 16.86 3.76 3.76 25.69 25.69 21.41 21.41 E 16.86 16.86 united health care epo "Stool analysis for blood, by peroxidase activity" cpt 82272 16.86 16.86 3.76 3.76 25.69 25.69 21.41 21.41 E 16.86 16.86 united health care hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 100.97 100.97 united health care ppo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 100.97 100.97 united health care pos "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 100.97 100.97 united health care hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 100.97 100.97 united health care epo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 31.21 31.21 161.54 161.54 134.62 134.62 O 100.97 100.97 united health care hmo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5055.3 5055.3 united health care ppo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5055.3 5055.3 united health care pos normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5055.3 5055.3 united health care hmo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5055.3 5055.3 united health care epo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 5055.3 5055.3 united health care hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 100.97 100.97 united health care ppo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 100.97 100.97 united health care pos "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 100.97 100.97 united health care hmo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 100.97 100.97 united health care epo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 100.97 100.97 united health care hmo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care ppo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care pos "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care epo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 9075.75 9075.75 united health care ppo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 9075.75 9075.75 united health care pos normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 9075.75 9075.75 united health care hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 9075.75 9075.75 united health care epo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 9075.75 9075.75 united health care hmo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 13467.02 13467.02 united health care ppo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 13467.02 13467.02 united health care pos normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 13467.02 13467.02 united health care hmo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 13467.02 13467.02 united health care epo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 13467.02 13467.02 united health care hmo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 61.22 61.22 united health care ppo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 61.22 61.22 united health care pos "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 61.22 61.22 united health care hmo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 61.22 61.22 united health care epo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 61.22 61.22 united health care hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 870.77 870.77 united health care ppo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 870.77 870.77 united health care pos "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 870.77 870.77 united health care hmo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 870.77 870.77 united health care epo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 870.77 870.77 united health care hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 6865.24 6865.24 united health care ppo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 6865.24 6865.24 united health care pos normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 6865.24 6865.24 united health care hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 6865.24 6865.24 united health care epo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 6865.24 6865.24 united health care hmo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 89.04 89.04 united health care ppo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 89.04 89.04 united health care pos "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 89.04 89.04 united health care hmo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 89.04 89.04 united health care epo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 89.04 89.04 united health care hmo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care ppo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care pos Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care epo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 91.43 91.43 united health care ppo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 91.43 91.43 united health care pos "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 91.43 91.43 united health care hmo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 91.43 91.43 united health care epo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 91.43 91.43 united health care hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 28.7 28.7 united health care ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 28.7 28.7 united health care pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 28.7 28.7 united health care hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 28.7 28.7 united health care epo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 28.7 28.7 united health care hmo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 219.42 219.42 219.42 219.42 351.07 351.07 292.56 292.56 O 219.42 219.42 united health care ppo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 219.42 219.42 219.42 219.42 351.07 351.07 292.56 292.56 O 219.42 219.42 united health care pos "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 219.42 219.42 219.42 219.42 351.07 351.07 292.56 292.56 O 219.42 219.42 united health care hmo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 219.42 219.42 219.42 219.42 351.07 351.07 292.56 292.56 O 219.42 219.42 united health care epo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 219.42 219.42 219.42 219.42 351.07 351.07 292.56 292.56 O 219.42 219.42 united health care hmo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 158.63 158.63 126.87 126.87 351.07 351.07 292.56 292.56 E 158.63 158.63 united health care ppo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 158.63 158.63 126.87 126.87 351.07 351.07 292.56 292.56 E 158.63 158.63 united health care pos "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 158.63 158.63 126.87 126.87 351.07 351.07 292.56 292.56 E 158.63 158.63 united health care hmo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 158.63 158.63 126.87 126.87 351.07 351.07 292.56 292.56 E 158.63 158.63 united health care epo "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" cpt 87631 158.63 158.63 126.87 126.87 351.07 351.07 292.56 292.56 E 158.63 158.63 united health care hmo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 97.48 97.48 united health care ppo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 97.48 97.48 united health care pos "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 97.48 97.48 united health care hmo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 97.48 97.48 united health care epo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 97.48 97.48 united health care hmo ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 4642.21 4642.21 united health care ppo ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 4642.21 4642.21 united health care pos ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 4642.21 4642.21 united health care hmo ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 4642.21 4642.21 united health care epo ringers lactate infusion cpt J7120 21270.9 21270.9 612.63 612.63 7456.24 7456.24 6213.53 6213.53 E 4642.21 4642.21 united health care hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 1477.69 1477.69 united health care ppo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 1477.69 1477.69 united health care pos ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 1477.69 1477.69 united health care hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 1477.69 1477.69 united health care epo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 1477.69 1477.69 united health care hmo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 47.7 47.7 united health care ppo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 47.7 47.7 united health care pos "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 47.7 47.7 united health care hmo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 47.7 47.7 united health care epo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 47.7 47.7 united health care hmo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care ppo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care pos Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care epo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 411.81 411.81 united health care hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care epo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care hmo 5% dextrose in lac ringers cpt J7121 6073.23 6073.23 478.56 478.56 3035.82 3035.82 2529.85 2529.85 E 6073.23 6073.23 united health care ppo 5% dextrose in lac ringers cpt J7121 6073.23 6073.23 478.56 478.56 3035.82 3035.82 2529.85 2529.85 E 6073.23 6073.23 united health care pos 5% dextrose in lac ringers cpt J7121 6073.23 6073.23 478.56 478.56 3035.82 3035.82 2529.85 2529.85 E 6073.23 6073.23 united health care hmo 5% dextrose in lac ringers cpt J7121 6073.23 6073.23 478.56 478.56 3035.82 3035.82 2529.85 2529.85 E 6073.23 6073.23 united health care epo 5% dextrose in lac ringers cpt J7121 6073.23 6073.23 478.56 478.56 3035.82 3035.82 2529.85 2529.85 E 6073.23 6073.23 united health care hmo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 842.46 842.46 united health care ppo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 842.46 842.46 united health care pos prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 842.46 842.46 united health care hmo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 842.46 842.46 united health care epo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 842.46 842.46 united health care hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care hmo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care epo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care hmo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 6390.02 6390.02 united health care ppo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 6390.02 6390.02 united health care pos prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 6390.02 6390.02 united health care hmo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 6390.02 6390.02 united health care epo prednisone ir or dr oral 1mg cpt J7512 6390.02 6390.02 436.31 436.31 5379.08 5379.08 4482.57 4482.57 O 6390.02 6390.02 united health care hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 14763.73 14763.73 united health care ppo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 14763.73 14763.73 united health care pos diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 14763.73 14763.73 united health care hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 14763.73 14763.73 united health care epo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 14763.73 14763.73 united health care hmo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 24671.23 24671.23 united health care ppo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 24671.23 24671.23 united health care pos poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 24671.23 24671.23 united health care hmo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 24671.23 24671.23 united health care epo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 24671.23 24671.23 united health care hmo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 172.79 172.79 united health care ppo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 172.79 172.79 united health care pos Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 172.79 172.79 united health care hmo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 172.79 172.79 united health care epo Ultrasound of fetal umbilical artery flow rate cpt 76820 172.79 172.79 29.68 29.68 263.3 263.3 219.42 219.42 O 172.79 172.79 united health care hmo "inj., bendeka 1 mg" cpt J9034 19816.19 19816.19 13726.13 13726.13 76845.62 76845.62 64038.02 64038.02 O 19816.19 19816.19 united health care ppo "inj., bendeka 1 mg" cpt J9034 19816.19 19816.19 13726.13 13726.13 76845.62 76845.62 64038.02 64038.02 O 19816.19 19816.19 united health care pos "inj., bendeka 1 mg" cpt J9034 19816.19 19816.19 13726.13 13726.13 76845.62 76845.62 64038.02 64038.02 O 19816.19 19816.19 united health care hmo "inj., bendeka 1 mg" cpt J9034 19816.19 19816.19 13726.13 13726.13 76845.62 76845.62 64038.02 64038.02 O 19816.19 19816.19 united health care epo "inj., bendeka 1 mg" cpt J9034 19816.19 19816.19 13726.13 13726.13 76845.62 76845.62 64038.02 64038.02 O 19816.19 19816.19 united health care hmo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 105.74 105.74 united health care ppo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 105.74 105.74 united health care pos Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 105.74 105.74 united health care hmo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 105.74 105.74 united health care epo Dehydroepiandrosterone (DHEA) hormone level cpt 82626 105.74 105.74 20.9 20.9 169.18 169.18 140.98 140.98 O 105.74 105.74 united health care hmo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 26280.06 26280.06 united health care ppo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 26280.06 26280.06 united health care pos diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 26280.06 26280.06 united health care hmo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 26280.06 26280.06 united health care epo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 26280.06 26280.06 united health care hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care hmo "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 10996.19 10996.19 united health care ppo "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 10996.19 10996.19 united health care pos "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 10996.19 10996.19 united health care hmo "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 10996.19 10996.19 united health care epo "Balloon dilation of dialysis segment, accessed through the skin, with imaging including radiological supervision and interpretation" cpt 36907 10996.19 10996.19 1444.99 1444.99 24849.47 24849.47 20707.89 20707.89 O 10996.19 10996.19 united health care hmo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 88.25 88.25 united health care ppo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 88.25 88.25 united health care pos "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 88.25 88.25 united health care hmo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 88.25 88.25 united health care epo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 88.25 88.25 united health care hmo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 10827.93 10827.93 united health care ppo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 10827.93 10827.93 united health care pos cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 10827.93 10827.93 united health care hmo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 10827.93 10827.93 united health care epo cisplatin 10 mg injection cpt J9060 10827.93 10827.93 832.09 832.09 26673.94 26673.94 22228.28 22228.28 O 10827.93 10827.93 united health care hmo "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 10996.19 10996.19 united health care ppo "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 10996.19 10996.19 united health care pos "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 10996.19 10996.19 united health care hmo "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 10996.19 10996.19 united health care epo "Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation" cpt 36901 10996.19 10996.19 1421.87 1421.87 8883.26 8883.26 7402.72 7402.72 O 10996.19 10996.19 united health care hmo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 4667.45 4667.45 united health care ppo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 4667.45 4667.45 united health care pos cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 4667.45 4667.45 united health care hmo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 4667.45 4667.45 united health care epo cyclophosphamide 100 mg inj cpt J9070 11286.59 11286.59 3343.78 3343.78 25827.6 25827.6 21523 21523 O 4667.45 4667.45 united health care hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1090.38 1090.38 united health care ppo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1090.38 1090.38 united health care pos Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1090.38 1090.38 united health care hmo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1090.38 1090.38 united health care epo Arterial puncture withdrawal of blood for diagnosis cpt 36600 1444.99 1444.99 224.22 224.22 1744.62 1744.62 1453.85 1453.85 O 1090.38 1090.38 united health care hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care ppo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care pos Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care hmo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care epo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care hmo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 10103.97 10103.97 united health care ppo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 10103.97 10103.97 united health care pos eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 10103.97 10103.97 united health care hmo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 10103.97 10103.97 united health care epo eribulin mesylate injection cpt J9179 10103.97 10103.97 2537.15 2537.15 15755.09 15755.09 13129.24 13129.24 O 10103.97 10103.97 united health care hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 147.87 147.87 united health care ppo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 147.87 147.87 united health care pos Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 147.87 147.87 united health care hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 147.87 147.87 united health care epo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 147.87 147.87 united health care hmo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 160.58 160.58 united health care ppo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 160.58 160.58 united health care pos Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 160.58 160.58 united health care hmo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 160.58 160.58 united health care epo Ultrasonic guidance imaging supervision and interpretation for insertion of needle cpt 76942 207.4 207.4 160.58 160.58 256.94 256.94 214.12 214.12 O 160.58 160.58 united health care hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 8558.99 8558.99 united health care ppo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 8558.99 8558.99 united health care pos Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 8558.99 8558.99 united health care hmo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 8558.99 8558.99 united health care epo Declotting infusion of implanted central venous access device or catheter cpt 36593 8558.99 8558.99 2507.56 2507.56 20050.8 20050.8 16709 16709 O 8558.99 8558.99 united health care hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4667.45 4667.45 united health care ppo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4667.45 4667.45 united health care pos fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4667.45 4667.45 united health care hmo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4667.45 4667.45 united health care epo fluorouracil injection cpt J9190 8184.57 8184.57 928.87 928.87 19294.19 19294.19 16078.49 16078.49 O 4667.45 4667.45 united health care hmo Renin (kidney enzyme) level cpt 84244 97.79 97.79 21.55 21.55 156.46 156.46 130.38 130.38 O 97.79 97.79 united health care ppo Renin (kidney enzyme) level cpt 84244 97.79 97.79 21.55 21.55 156.46 156.46 130.38 130.38 O 97.79 97.79 united health care pos Renin (kidney enzyme) level cpt 84244 97.79 97.79 21.55 21.55 156.46 156.46 130.38 130.38 O 97.79 97.79 united health care hmo Renin (kidney enzyme) level cpt 84244 97.79 97.79 21.55 21.55 156.46 156.46 130.38 130.38 O 97.79 97.79 united health care epo Renin (kidney enzyme) level cpt 84244 97.79 97.79 21.55 21.55 156.46 156.46 130.38 130.38 O 97.79 97.79 united health care hmo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 13474.58 13474.58 united health care ppo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 13474.58 13474.58 united health care pos poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 13474.58 13474.58 united health care hmo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 13474.58 13474.58 united health care epo poisoning and toxic effects of drugs without mcc ms-drg 918 13474.58 13474.58 2378.72 2378.72 17407.45 17407.45 14506.21 14506.21 I 13474.58 13474.58 united health care hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 147.87 147.87 united health care ppo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 147.87 147.87 united health care pos Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 147.87 147.87 united health care hmo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 147.87 147.87 united health care epo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 147.87 147.87 united health care hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 173.63 173.63 united health care ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 173.63 173.63 united health care pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 173.63 173.63 united health care hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 173.63 173.63 united health care epo Collection of blood specimen from central or peripheral venous catheter cpt 36592 11362.44 11362.44 96.59 96.59 3908.45 3908.45 3257.04 3257.04 O 173.63 173.63 united health care hmo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7348.19 7348.19 united health care ppo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7348.19 7348.19 united health care pos in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7348.19 7348.19 united health care hmo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7348.19 7348.19 united health care epo in gemcitabine hcl nos 200mg cpt J9201 7649.74 7649.74 341.79 341.79 7331.44 7331.44 6109.53 6109.53 O 7348.19 7348.19 united health care hmo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 11714.97 11714.97 united health care ppo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 11714.97 11714.97 united health care pos "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 11714.97 11714.97 united health care hmo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 11714.97 11714.97 united health care epo "Removal of tailbone cyst, extensive" cpt 11771 11714.97 11714.97 4573.79 4573.79 18530.16 18530.16 15441.8 15441.8 O 11714.97 11714.97 united health care hmo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 78.71 78.71 united health care ppo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 78.71 78.71 united health care pos "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 78.71 78.71 united health care hmo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 78.71 78.71 united health care epo "Protein measurement, serum" cpt 84165 78.71 78.71 9.55 9.55 125.93 125.93 104.94 104.94 O 78.71 78.71 united health care hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 67.41 67.41 united health care ppo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 67.41 67.41 united health care pos "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 67.41 67.41 united health care hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 67.41 67.41 united health care epo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 67.41 67.41 united health care hmo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 2006.58 2006.58 united health care ppo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 2006.58 2006.58 united health care pos leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 2006.58 2006.58 united health care hmo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 2006.58 2006.58 united health care epo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 2006.58 2006.58 united health care hmo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 4667.45 4667.45 united health care ppo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 4667.45 4667.45 united health care pos methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 4667.45 4667.45 united health care hmo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 4667.45 4667.45 united health care epo methotrexate sodium inj cpt J9260 10076.53 10076.53 195.62 195.62 7467.91 7467.91 6223.26 6223.26 O 4667.45 4667.45 united health care hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 2110.35 2110.35 united health care ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 2110.35 2110.35 united health care pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 2110.35 2110.35 united health care hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 2110.35 2110.35 united health care epo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 2110.35 2110.35 united health care hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 177.88 177.88 33.15 33.15 271.06 271.06 225.88 225.88 E 177.88 177.88 united health care ppo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 177.88 177.88 33.15 33.15 271.06 271.06 225.88 225.88 E 177.88 177.88 united health care pos "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 177.88 177.88 33.15 33.15 271.06 271.06 225.88 225.88 E 177.88 177.88 united health care hmo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 177.88 177.88 33.15 33.15 271.06 271.06 225.88 225.88 E 177.88 177.88 united health care epo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 177.88 177.88 33.15 33.15 271.06 271.06 225.88 225.88 E 177.88 177.88 united health care hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 124.02 124.02 united health care ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 124.02 124.02 united health care pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 124.02 124.02 united health care hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 124.02 124.02 united health care epo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 124.02 124.02 united health care hmo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 7348.19 7348.19 united health care ppo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 7348.19 7348.19 united health care pos paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 7348.19 7348.19 united health care hmo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 7348.19 7348.19 united health care epo paclitaxel protein bound cpt J9264 7348.19 7348.19 2255.17 2255.17 11757.1 11757.1 9797.58 9797.58 O 7348.19 7348.19 united health care hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care epo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 99.45 99.45 united health care hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 6018.33 6018.33 united health care ppo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 6018.33 6018.33 united health care pos "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 6018.33 6018.33 united health care hmo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 6018.33 6018.33 united health care epo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc" ms-drg 641 6018.33 6018.33 2500.28 2500.28 19856.36 19856.36 16546.97 16546.97 I 6018.33 6018.33 united health care hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 57.31 57.31 united health care ppo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 57.31 57.31 united health care pos "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 57.31 57.31 united health care hmo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 57.31 57.31 united health care epo "Total protein level, urine" cpt 84156 57.31 57.31 3.26 3.26 86.52 86.52 72.1 72.1 O 57.31 57.31 united health care hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 26265.21 26265.21 united health care ppo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 26265.21 26265.21 united health care pos inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 26265.21 26265.21 united health care hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 26265.21 26265.21 united health care epo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 26265.21 26265.21 united health care hmo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 49.29 49.29 united health care ppo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 49.29 49.29 united health care pos "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 49.29 49.29 united health care hmo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 49.29 49.29 united health care epo "Total protein level, blood" cpt 84155 49.29 49.29 3.26 3.26 78.86 78.86 65.72 65.72 O 49.29 49.29 united health care hmo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 18.36 18.36 united health care ppo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 18.36 18.36 united health care pos "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 18.36 18.36 united health care hmo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 18.36 18.36 united health care epo "Calcium level, total" cpt 82310 18.36 18.36 4.59 4.59 41.84 41.84 34.87 34.87 O 18.36 18.36 united health care hmo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 78.38 78.38 united health care ppo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 78.38 78.38 united health care pos Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 78.38 78.38 united health care hmo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 78.38 78.38 united health care epo Prolactin (milk producing hormone) level cpt 84146 78.38 78.38 17.24 17.24 125.41 125.41 104.51 104.51 O 78.38 78.38 united health care hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care epo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 217.43 217.43 31.21 31.21 347.89 347.89 289.91 289.91 E 217.43 217.43 united health care hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 12335.28 12335.28 united health care ppo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 12335.28 12335.28 united health care pos "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 12335.28 12335.28 united health care hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 12335.28 12335.28 united health care epo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 12335.28 12335.28 united health care hmo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 80.3 80.3 united health care ppo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 80.3 80.3 united health care pos Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 80.3 80.3 united health care hmo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 80.3 80.3 united health care epo Dehydroepiandrosterone (DHEA-S) hormone level cpt 82627 80.3 80.3 17.78 17.78 128.47 128.47 107.06 107.06 O 80.3 80.3 united health care hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 72.5 72.5 united health care hmo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 16016.09 16016.09 united health care ppo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 16016.09 16016.09 united health care pos "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 16016.09 16016.09 united health care hmo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 16016.09 16016.09 united health care epo "inj rituximab, hyaluronidase" cpt J9311 16016.09 16016.09 4264.13 4264.13 26906.82 26906.82 22422.35 22422.35 O 16016.09 16016.09 united health care hmo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 65.8 65.8 united health care ppo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 65.8 65.8 united health care pos Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 65.8 65.8 united health care hmo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 65.8 65.8 united health care epo Procalcitonin (hormone) level cpt 84145 65.8 65.8 20.21 20.21 105.58 105.58 87.98 87.98 O 65.8 65.8 united health care hmo "inj., rituximab, 10 mg" cpt J9312 23327.69 23327.69 6727.46 6727.46 33944.59 33944.59 28287.16 28287.16 O 23327.69 23327.69 united health care ppo "inj., rituximab, 10 mg" cpt J9312 23327.69 23327.69 6727.46 6727.46 33944.59 33944.59 28287.16 28287.16 O 23327.69 23327.69 united health care pos "inj., rituximab, 10 mg" cpt J9312 23327.69 23327.69 6727.46 6727.46 33944.59 33944.59 28287.16 28287.16 O 23327.69 23327.69 united health care hmo "inj., rituximab, 10 mg" cpt J9312 23327.69 23327.69 6727.46 6727.46 33944.59 33944.59 28287.16 28287.16 O 23327.69 23327.69 united health care epo "inj., rituximab, 10 mg" cpt J9312 23327.69 23327.69 6727.46 6727.46 33944.59 33944.59 28287.16 28287.16 O 23327.69 23327.69 united health care hmo Procalcitonin (hormone) level cpt 84145 87.98 87.98 24.21 24.21 105.58 105.58 87.98 87.98 E 65.99 65.99 united health care ppo Procalcitonin (hormone) level cpt 84145 87.98 87.98 24.21 24.21 105.58 105.58 87.98 87.98 E 65.99 65.99 united health care pos Procalcitonin (hormone) level cpt 84145 87.98 87.98 24.21 24.21 105.58 105.58 87.98 87.98 E 65.99 65.99 united health care hmo Procalcitonin (hormone) level cpt 84145 87.98 87.98 24.21 24.21 105.58 105.58 87.98 87.98 E 65.99 65.99 united health care epo Procalcitonin (hormone) level cpt 84145 87.98 87.98 24.21 24.21 105.58 105.58 87.98 87.98 E 65.99 65.99 united health care hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care pos "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care epo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 17.83 17.83 116 116 96.67 96.67 E 72.5 72.5 united health care hmo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 3914.61 3914.61 united health care ppo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 3914.61 3914.61 united health care pos Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 3914.61 3914.61 united health care hmo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 3914.61 3914.61 united health care epo Hydration infusion into a vein cpt 96361 3914.61 3914.61 819.35 819.35 5749.4 5749.4 4791.17 4791.17 O 3914.61 3914.61 united health care hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 5526.84 5526.84 united health care ppo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 5526.84 5526.84 united health care pos "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 5526.84 5526.84 united health care hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 5526.84 5526.84 united health care epo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 5526.84 5526.84 united health care hmo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care ppo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care pos Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care hmo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care epo Carboxyhemoglobin (protein) level cpt 82375 73.94 73.94 10.96 10.96 118.3 118.3 98.58 98.58 O 73.94 73.94 united health care hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care ppo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care pos Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care epo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 237.71 237.71 united health care ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 237.71 237.71 united health care pos "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 237.71 237.71 united health care hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 237.71 237.71 united health care epo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 237.71 237.71 united health care hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care ppo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care pos Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care hmo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care epo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 6865.24 6865.24 united health care ppo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 6865.24 6865.24 united health care pos Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 6865.24 6865.24 united health care hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 6865.24 6865.24 united health care epo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 6865.24 6865.24 united health care hmo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care ppo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care pos Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care hmo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care epo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 68.29 68.29 united health care hmo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care ppo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care pos Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care hmo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care epo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care hmo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care ppo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care pos Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care hmo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care epo Detection test by immunoassay technique for Hepatitis B surface antigen cpt 87340 53.98 53.98 9.19 9.19 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care hmo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 3837.05 3837.05 united health care ppo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 3837.05 3837.05 united health care pos Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 3837.05 3837.05 united health care hmo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 3837.05 3837.05 united health care epo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 3837.05 3837.05 united health care hmo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 3837.05 3837.05 united health care ppo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 3837.05 3837.05 united health care pos rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 3837.05 3837.05 united health care hmo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 3837.05 3837.05 united health care epo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 3837.05 3837.05 united health care hmo "Removal of growth (3.1 to 4.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11424 12136.25 12136.25 4009.69 4009.69 19418 19418 16181.67 16181.67 O 12136.25 12136.25 united health care ppo "Removal of growth (3.1 to 4.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11424 12136.25 12136.25 4009.69 4009.69 19418 19418 16181.67 16181.67 O 12136.25 12136.25 united health care pos "Removal of growth (3.1 to 4.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11424 12136.25 12136.25 4009.69 4009.69 19418 19418 16181.67 16181.67 O 12136.25 12136.25 united health care hmo "Removal of growth (3.1 to 4.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11424 12136.25 12136.25 4009.69 4009.69 19418 19418 16181.67 16181.67 O 12136.25 12136.25 united health care epo "Removal of growth (3.1 to 4.0 centimeters) of the scalp, neck, hands, feet, or genitals" cpt 11424 12136.25 12136.25 4009.69 4009.69 19418 19418 16181.67 16181.67 O 12136.25 12136.25 united health care hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 6865.24 6865.24 united health care ppo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 6865.24 6865.24 united health care pos rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 6865.24 6865.24 united health care hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 6865.24 6865.24 united health care epo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 6865.24 6865.24 united health care hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 246.13 246.13 united health care ppo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 246.13 246.13 united health care pos "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 246.13 246.13 united health care hmo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 246.13 246.13 united health care epo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 246.13 246.13 united health care hmo renal failure without cc/mcc ms-drg 684 10924.55 10924.55 3036.64 3036.64 15925.09 15925.09 13270.91 13270.91 I 10924.55 10924.55 united health care ppo renal failure without cc/mcc ms-drg 684 10924.55 10924.55 3036.64 3036.64 15925.09 15925.09 13270.91 13270.91 I 10924.55 10924.55 united health care pos renal failure without cc/mcc ms-drg 684 10924.55 10924.55 3036.64 3036.64 15925.09 15925.09 13270.91 13270.91 I 10924.55 10924.55 united health care hmo renal failure without cc/mcc ms-drg 684 10924.55 10924.55 3036.64 3036.64 15925.09 15925.09 13270.91 13270.91 I 10924.55 10924.55 united health care epo renal failure without cc/mcc ms-drg 684 10924.55 10924.55 3036.64 3036.64 15925.09 15925.09 13270.91 13270.91 I 10924.55 10924.55 united health care hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 2689.93 2689.93 united health care ppo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 2689.93 2689.93 united health care pos Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 2689.93 2689.93 united health care hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 2689.93 2689.93 united health care epo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 2689.93 2689.93 united health care hmo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care ppo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care pos Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care hmo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care epo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care hmo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care ppo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care pos Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care hmo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care epo Prealbumin (protein) level cpt 84134 49.76 49.76 12.98 12.98 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care hmo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 698.81 698.81 united health care ppo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 698.81 698.81 united health care pos "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 698.81 698.81 united health care hmo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 698.81 698.81 united health care epo "Management of radiation therapy simulation, simple" cpt 77280 698.81 698.81 110.46 110.46 1118.09 1118.09 931.74 931.74 O 698.81 698.81 united health care hmo "albumin (human), 25%, 50ml" cpt P9047 6865.24 6865.24 849.62 849.62 14211.08 14211.08 11842.57 11842.57 O 6865.24 6865.24 united health care ppo "albumin (human), 25%, 50ml" cpt P9047 6865.24 6865.24 849.62 849.62 14211.08 14211.08 11842.57 11842.57 O 6865.24 6865.24 united health care pos "albumin (human), 25%, 50ml" cpt P9047 6865.24 6865.24 849.62 849.62 14211.08 14211.08 11842.57 11842.57 O 6865.24 6865.24 united health care hmo "albumin (human), 25%, 50ml" cpt P9047 6865.24 6865.24 849.62 849.62 14211.08 14211.08 11842.57 11842.57 O 6865.24 6865.24 united health care epo "albumin (human), 25%, 50ml" cpt P9047 6865.24 6865.24 849.62 849.62 14211.08 14211.08 11842.57 11842.57 O 6865.24 6865.24 united health care hmo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 10370.93 10370.93 united health care ppo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 10370.93 10370.93 united health care pos kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 10370.93 10370.93 united health care hmo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 10370.93 10370.93 united health care epo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 10370.93 10370.93 united health care hmo fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 1316.33 1316.33 united health care ppo fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 1316.33 1316.33 united health care pos fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 1316.33 1316.33 united health care hmo fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 1316.33 1316.33 united health care epo fosphenytoin inj pe cpt Q2009 6636.16 6636.16 944.61 944.61 8945.38 8945.38 7454.48 7454.48 O 1316.33 1316.33 united health care hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care ppo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care pos Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care epo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 40.46 40.46 united health care hmo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 4642.21 4642.21 united health care ppo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 4642.21 4642.21 united health care pos Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 4642.21 4642.21 united health care hmo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 4642.21 4642.21 united health care epo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 4642.21 4642.21 united health care hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1318.11 1318.11 united health care ppo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1318.11 1318.11 united health care pos "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1318.11 1318.11 united health care hmo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1318.11 1318.11 united health care epo "Management of radiation therapy, simulation, complex" cpt 77290 1318.11 1318.11 296.91 296.91 2108.98 2108.98 1757.48 1757.48 O 1318.11 1318.11 united health care hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care ppo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care pos Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care hmo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care epo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 42.48 42.48 10.66 10.66 64.74 64.74 53.95 53.95 E 42.48 42.48 united health care hmo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 182.3 182.3 united health care ppo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 182.3 182.3 united health care pos Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 182.3 182.3 united health care hmo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 182.3 182.3 united health care epo Cervicovaginal secretion of placenta protein cpt 84112 182.3 182.3 87.27 87.27 277.8 277.8 231.5 231.5 O 182.3 182.3 united health care hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1298.24 1298.24 united health care ppo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1298.24 1298.24 united health care pos "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1298.24 1298.24 united health care hmo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1298.24 1298.24 united health care epo "Management of radiation therapy, 3D" cpt 77295 1298.24 1298.24 223.56 223.56 2077.18 2077.18 1730.98 1730.98 O 1298.24 1298.24 united health care hmo "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 4865.15 4865.15 united health care ppo "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 4865.15 4865.15 united health care pos "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 4865.15 4865.15 united health care hmo "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 4865.15 4865.15 united health care epo "hocm 150-199mg/ml iodine,1ml" cpt Q9959 4865.15 4865.15 1934.02 1934.02 18299.95 18299.95 15249.96 15249.96 E 4865.15 4865.15 united health care hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 376.55 376.55 united health care ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 376.55 376.55 united health care pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 376.55 376.55 united health care hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 376.55 376.55 united health care epo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 376.55 376.55 united health care hmo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care ppo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care pos Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care hmo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care epo Phosphate level cpt 84100 27.03 27.03 4.22 4.22 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care hmo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care ppo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care pos Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care hmo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care epo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care hmo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 E 68.37 68.37 united health care ppo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 E 68.37 68.37 united health care pos Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 E 68.37 68.37 united health care hmo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 E 68.37 68.37 united health care epo Smear for infectious agents cpt 87210 68.37 68.37 5.18 5.18 109.39 109.39 91.16 91.16 E 68.37 68.37 united health care hmo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 112.1 112.1 united health care ppo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 112.1 112.1 united health care pos Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 112.1 112.1 united health care hmo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 112.1 112.1 united health care epo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 112.1 112.1 united health care hmo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 58.99 58.99 united health care ppo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 58.99 58.99 united health care pos Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 58.99 58.99 united health care hmo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 58.99 58.99 united health care epo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 58.99 58.99 united health care hmo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 168.54 168.54 united health care ppo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 168.54 168.54 united health care pos "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 168.54 168.54 united health care hmo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 168.54 168.54 united health care epo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 168.54 168.54 united health care hmo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 3914.61 3914.61 united health care ppo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 3914.61 3914.61 united health care pos "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 3914.61 3914.61 united health care hmo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 3914.61 3914.61 united health care epo "injection, famotidine, 20 mg" cpt S0028 6037.32 6037.32 1004.16 1004.16 14447.38 14447.38 12039.48 12039.48 O 3914.61 3914.61 united health care hmo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 23111.69 23111.69 united health care ppo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 23111.69 23111.69 united health care pos robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 23111.69 23111.69 united health care hmo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 23111.69 23111.69 united health care epo robotic surgical system cpt S2900 23111.69 23111.69 4282.09 4282.09 26894.08 26894.08 22411.73 22411.73 O 23111.69 23111.69 united health care hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 32.04 32.04 united health care ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 32.04 32.04 united health care pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 32.04 32.04 united health care hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 32.04 32.04 united health care epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 32.04 32.04 united health care hmo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 111.3 111.3 united health care ppo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 111.3 111.3 united health care pos lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 111.3 111.3 united health care hmo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 111.3 111.3 united health care epo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 111.3 111.3 united health care hmo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 72.35 72.35 united health care ppo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 72.35 72.35 united health care pos Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 72.35 72.35 united health care hmo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 72.35 72.35 united health care epo Stool calprotectin (protein) level cpt 83993 72.35 72.35 14.08 14.08 115.75 115.75 96.46 96.46 O 72.35 72.35 united health care hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 61.94 61.94 united health care ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 61.94 61.94 united health care pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 61.94 61.94 united health care hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 61.94 61.94 united health care epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 61.94 61.94 7.69 7.69 94.38 94.38 78.65 78.65 E 61.94 61.94 united health care hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 184.44 184.44 united health care ppo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 184.44 184.44 united health care pos Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 184.44 184.44 united health care hmo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 184.44 184.44 united health care epo Calculation of radiation therapy dose cpt 77300 224.29 224.29 28.88 28.88 295.1 295.1 245.92 245.92 O 184.44 184.44 united health care hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 11.13 11.13 united health care ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 11.13 11.13 united health care pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 11.13 11.13 united health care hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 11.13 11.13 united health care epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" cpt 87181 11.13 11.13 4.23 4.23 17.81 17.81 14.84 14.84 O 11.13 11.13 united health care hmo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 83.48 83.48 united health care ppo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 83.48 83.48 united health care pos Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 83.48 83.48 united health care hmo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 83.48 83.48 united health care epo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 83.48 83.48 united health care hmo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 102.67 102.67 united health care ppo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 102.67 102.67 united health care pos Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 102.67 102.67 united health care hmo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 102.67 102.67 united health care epo Parathormone (parathyroid hormone) level cpt 83970 102.67 102.67 29.88 29.88 147.6 147.6 123 123 O 102.67 102.67 united health care hmo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 12264.64 12264.64 united health care ppo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 12264.64 12264.64 united health care pos multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 12264.64 12264.64 united health care hmo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 12264.64 12264.64 united health care epo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 12264.64 12264.64 united health care hmo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 2110.35 2110.35 united health care ppo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 2110.35 2110.35 united health care pos General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 2110.35 2110.35 united health care hmo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 2110.35 2110.35 united health care epo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 2110.35 2110.35 united health care hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 5714.16 5714.16 united health care ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 5714.16 5714.16 united health care pos Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 5714.16 5714.16 united health care hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 5714.16 5714.16 united health care epo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 5714.16 5714.16 united health care hmo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 16775.47 16775.47 united health care ppo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 16775.47 16775.47 united health care pos General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 16775.47 16775.47 united health care hmo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 16775.47 16775.47 united health care epo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 16775.47 16775.47 united health care hmo IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3792.31 3792.31 united health care ppo IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3792.31 3792.31 united health care pos IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3792.31 3792.31 united health care hmo IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3792.31 3792.31 united health care epo IVsolutions revCode 258 3792.31 3792.31 2415.74 2415.74 18919.39 18919.39 15766.16 15766.16 E 3792.31 3792.31 united health care hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 131.18 131.18 united health care ppo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 131.18 131.18 united health care pos "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 131.18 131.18 united health care hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 131.18 131.18 united health care epo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 179.27 179.27 5.79 5.79 209.88 209.88 174.9 174.9 E 131.18 131.18 united health care hmo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 11376.64 11376.64 united health care ppo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 11376.64 11376.64 united health care pos IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 11376.64 11376.64 united health care hmo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 11376.64 11376.64 united health care epo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 11376.64 11376.64 united health care hmo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 7240.33 7240.33 united health care ppo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 7240.33 7240.33 united health care pos General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 7240.33 7240.33 united health care hmo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 7240.33 7240.33 united health care epo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 7240.33 7240.33 united health care hmo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3909.17 3909.17 united health care ppo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3909.17 3909.17 united health care pos General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3909.17 3909.17 united health care hmo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3909.17 3909.17 united health care epo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 3909.17 3909.17 united health care hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 131.18 131.18 united health care ppo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 131.18 131.18 united health care pos "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 131.18 131.18 united health care hmo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 131.18 131.18 united health care epo "Creatine kinase (cardiac enzyme) level, total" cpt 82550 131.18 131.18 5.79 5.79 68.11 68.11 56.76 56.76 O 131.18 131.18 united health care hmo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 11003.96 11003.96 united health care ppo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 11003.96 11003.96 united health care pos postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 11003.96 11003.96 united health care hmo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 11003.96 11003.96 united health care epo postpartum and post abortion diagnoses without o.r. procedures ms-drg 776 11003.96 11003.96 2596.24 2596.24 9828.08 9828.08 8190.07 8190.07 I 11003.96 11003.96 united health care hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 123.06 123.06 united health care ppo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 123.06 123.06 united health care pos "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 123.06 123.06 united health care hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 123.06 123.06 united health care epo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 426.6 426.6 10.27 10.27 196.9 196.9 164.08 164.08 E 123.06 123.06 united health care hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 89.87 89.87 united health care ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 89.87 89.87 united health care pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 89.87 89.87 united health care hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 89.87 89.87 united health care epo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 89.87 89.87 united health care hmo cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 23094.84 23094.84 united health care ppo cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 23094.84 23094.84 united health care pos cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 23094.84 23094.84 united health care hmo cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 23094.84 23094.84 united health care epo cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 23094.84 23094.84 united health care hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 87.68 87.68 united health care ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 87.68 87.68 united health care pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 87.68 87.68 united health care hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 87.68 87.68 united health care epo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 122.75 122.75 34.92 34.92 140.29 140.29 116.91 116.91 E 87.68 87.68 united health care hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.49 17.49 united health care ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.49 17.49 united health care pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.49 17.49 united health care hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.49 17.49 united health care epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.49 17.49 united health care hmo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 17092.44 17092.44 united health care ppo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 17092.44 17092.44 united health care pos cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 17092.44 17092.44 united health care hmo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 17092.44 17092.44 united health care epo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 17092.44 17092.44 united health care hmo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 3444.67 3444.67 united health care ppo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 3444.67 3444.67 united health care pos Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 3444.67 3444.67 united health care hmo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 3444.67 3444.67 united health care epo Removal of skin and tissue cpt 11045 3444.67 3444.67 258.55 258.55 3566.03 3566.03 2971.69 2971.69 O 3444.67 3444.67 united health care hmo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 1722.3 1722.3 united health care ppo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 1722.3 1722.3 united health care pos Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 1722.3 1722.3 united health care hmo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 1722.3 1722.3 united health care epo Emergent insertion of breathing tube into windpipe cartilage using an endoscope cpt 31500 2333.86 2333.86 766.73 766.73 4190.2 4190.2 3491.83 3491.83 E 1722.3 1722.3 united health care hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 24.65 24.65 united health care ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 24.65 24.65 united health care pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 24.65 24.65 united health care hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 24.65 24.65 united health care epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 24.65 24.65 4.61 4.61 39.43 39.43 32.86 32.86 E 24.65 24.65 united health care hmo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 53.27 53.27 united health care ppo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 53.27 53.27 united health care pos Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 53.27 53.27 united health care hmo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 53.27 53.27 united health care epo Metanephrines level cpt 83835 53.27 53.27 15.07 15.07 87.36 87.36 72.8 72.8 O 53.27 53.27 united health care hmo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 5212.02 5212.02 united health care ppo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 5212.02 5212.02 united health care pos Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 5212.02 5212.02 united health care hmo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 5212.02 5212.02 united health care epo Management of modulation radiotherapy planning cpt 77301 5212.02 5212.02 1089.98 1089.98 8339.23 8339.23 6949.36 6949.36 O 5212.02 5212.02 united health care hmo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care ppo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care pos Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care hmo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care epo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care hmo Radiation therapy plan intermediate for insertion of radioactive implant cpt 77317 639.98 639.98 292.16 292.16 1023.96 1023.96 853.3 853.3 O 639.98 639.98 united health care ppo Radiation therapy plan intermediate for insertion of radioactive implant cpt 77317 639.98 639.98 292.16 292.16 1023.96 1023.96 853.3 853.3 O 639.98 639.98 united health care pos Radiation therapy plan intermediate for insertion of radioactive implant cpt 77317 639.98 639.98 292.16 292.16 1023.96 1023.96 853.3 853.3 O 639.98 639.98 united health care hmo Radiation therapy plan intermediate for insertion of radioactive implant cpt 77317 639.98 639.98 292.16 292.16 1023.96 1023.96 853.3 853.3 O 639.98 639.98 united health care epo Radiation therapy plan intermediate for insertion of radioactive implant cpt 77317 639.98 639.98 292.16 292.16 1023.96 1023.96 853.3 853.3 O 639.98 639.98 united health care hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 48.5 48.5 united health care ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 48.5 48.5 united health care pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 48.5 48.5 united health care hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 48.5 48.5 united health care epo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 48.5 48.5 united health care hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 126.14 126.14 united health care ppo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 126.14 126.14 united health care pos "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 126.14 126.14 united health care hmo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 126.14 126.14 united health care epo "Creatine kinase (cardiac enzyme) level, MB fraction only" cpt 82553 126.14 126.14 10.27 10.27 185.76 185.76 154.8 154.8 O 126.14 126.14 united health care hmo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 16311.44 16311.44 united health care ppo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 16311.44 16311.44 united health care pos Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 16311.44 16311.44 united health care hmo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 16311.44 16311.44 united health care epo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 16311.44 16311.44 united health care hmo Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 12553.76 12553.76 united health care ppo Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 12553.76 12553.76 united health care pos Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 12553.76 12553.76 united health care hmo Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 12553.76 12553.76 united health care epo Removal or shaving of knee joint cartilage using an endoscope cpt 29877 12553.76 12553.76 1328.48 1328.48 20960.54 20960.54 17467.12 17467.12 O 12553.76 12553.76 united health care hmo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 160.59 160.59 united health care ppo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 160.59 160.59 united health care pos "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 160.59 160.59 united health care hmo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 160.59 160.59 united health care epo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 160.59 160.59 united health care hmo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 30.37 30.37 united health care ppo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 30.37 30.37 united health care pos Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 30.37 30.37 united health care hmo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 30.37 30.37 united health care epo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 30.37 30.37 united health care hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 46.07 46.07 united health care ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 46.07 46.07 united health care pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 46.07 46.07 united health care hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 46.07 46.07 united health care epo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 46.07 46.07 united health care hmo "Radiation treatment devices, design and construction, simple" cpt 77332 217.04 217.04 111.3 111.3 347.26 347.26 289.38 289.38 O 217.04 217.04 united health care ppo "Radiation treatment devices, design and construction, simple" cpt 77332 217.04 217.04 111.3 111.3 347.26 347.26 289.38 289.38 O 217.04 217.04 united health care pos "Radiation treatment devices, design and construction, simple" cpt 77332 217.04 217.04 111.3 111.3 347.26 347.26 289.38 289.38 O 217.04 217.04 united health care hmo "Radiation treatment devices, design and construction, simple" cpt 77332 217.04 217.04 111.3 111.3 347.26 347.26 289.38 289.38 O 217.04 217.04 united health care epo "Radiation treatment devices, design and construction, simple" cpt 77332 217.04 217.04 111.3 111.3 347.26 347.26 289.38 289.38 O 217.04 217.04 united health care hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care epo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care hmo Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 37.22 37.22 united health care ppo Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 37.22 37.22 united health care pos Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 37.22 37.22 united health care hmo Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 37.22 37.22 united health care epo Bacterial culture for aerobic isolates cpt 87077 37.22 37.22 7.19 7.19 56.72 56.72 47.27 47.27 E 37.22 37.22 united health care hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 403.86 403.86 united health care ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 403.86 403.86 united health care pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 403.86 403.86 united health care hmo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 403.86 403.86 united health care epo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 403.86 403.86 united health care hmo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 129.14 129.14 united health care ppo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 129.14 129.14 united health care pos Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 129.14 129.14 united health care hmo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 129.14 129.14 united health care epo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 129.14 129.14 united health care hmo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 10065.37 10065.37 united health care ppo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 10065.37 10065.37 united health care pos vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 10065.37 10065.37 united health care hmo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 10065.37 10065.37 united health care epo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 10065.37 10065.37 united health care hmo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 16160.85 16160.85 united health care ppo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 16160.85 16160.85 united health care pos General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 16160.85 16160.85 united health care hmo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 16160.85 16160.85 united health care epo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 16160.85 16160.85 united health care hmo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 57.31 57.31 united health care ppo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 57.31 57.31 united health care pos "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 57.31 57.31 united health care hmo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 57.31 57.31 united health care epo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 57.31 57.31 united health care hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 21865.72 21865.72 united health care ppo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 21865.72 21865.72 united health care pos intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 21865.72 21865.72 united health care hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 21865.72 21865.72 united health care epo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 21865.72 21865.72 united health care hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 194.78 194.78 united health care ppo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 194.78 194.78 united health care pos Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 194.78 194.78 united health care hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 194.78 194.78 united health care epo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 194.78 194.78 united health care hmo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 2724.97 2724.97 united health care ppo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 2724.97 2724.97 united health care pos Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 2724.97 2724.97 united health care hmo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 2724.97 2724.97 united health care epo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 2724.97 2724.97 united health care hmo Open treatment of dislocation at the connection of the midfoot to the forefoot cpt 28615 26638.49 26638.49 26638.49 26638.49 42621.58 42621.58 35517.98 35517.98 O 26638.49 26638.49 united health care ppo Open treatment of dislocation at the connection of the midfoot to the forefoot cpt 28615 26638.49 26638.49 26638.49 26638.49 42621.58 42621.58 35517.98 35517.98 O 26638.49 26638.49 united health care pos Open treatment of dislocation at the connection of the midfoot to the forefoot cpt 28615 26638.49 26638.49 26638.49 26638.49 42621.58 42621.58 35517.98 35517.98 O 26638.49 26638.49 united health care hmo Open treatment of dislocation at the connection of the midfoot to the forefoot cpt 28615 26638.49 26638.49 26638.49 26638.49 42621.58 42621.58 35517.98 35517.98 O 26638.49 26638.49 united health care epo Open treatment of dislocation at the connection of the midfoot to the forefoot cpt 28615 26638.49 26638.49 26638.49 26638.49 42621.58 42621.58 35517.98 35517.98 O 26638.49 26638.49 united health care hmo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care ppo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care pos "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care hmo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care epo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 43.88 43.88 united health care hmo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 20.27 20.27 united health care ppo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 20.27 20.27 united health care pos Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 20.27 20.27 united health care hmo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 20.27 20.27 united health care epo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 20.27 20.27 united health care hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 3792.31 3792.31 united health care ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 3792.31 3792.31 united health care pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 3792.31 3792.31 united health care hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 3792.31 3792.31 united health care epo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 3792.31 3792.31 united health care hmo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care ppo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care pos "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care hmo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care epo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 35.46 35.46 united health care hmo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 8080.24 8080.24 united health care ppo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 8080.24 8080.24 united health care pos vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 8080.24 8080.24 united health care hmo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 8080.24 8080.24 united health care epo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 8080.24 8080.24 united health care hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 1392.99 1392.99 united health care ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 1392.99 1392.99 united health care pos Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 1392.99 1392.99 united health care hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 1392.99 1392.99 united health care epo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 1392.99 1392.99 united health care hmo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 90.32 90.32 united health care ppo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 90.32 90.32 united health care pos Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 90.32 90.32 united health care hmo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 90.32 90.32 united health care epo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 90.32 90.32 united health care hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 3587.65 3587.65 united health care ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 3587.65 3587.65 united health care pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 3587.65 3587.65 united health care hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 3587.65 3587.65 united health care epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 3587.65 3587.65 united health care hmo "Stool culture, additional pathogens" cpt 87046 37.23 37.23 8.4 8.4 56.72 56.72 47.27 47.27 E 37.23 37.23 united health care ppo "Stool culture, additional pathogens" cpt 87046 37.23 37.23 8.4 8.4 56.72 56.72 47.27 47.27 E 37.23 37.23 united health care pos "Stool culture, additional pathogens" cpt 87046 37.23 37.23 8.4 8.4 56.72 56.72 47.27 47.27 E 37.23 37.23 united health care hmo "Stool culture, additional pathogens" cpt 87046 37.23 37.23 8.4 8.4 56.72 56.72 47.27 47.27 E 37.23 37.23 united health care epo "Stool culture, additional pathogens" cpt 87046 37.23 37.23 8.4 8.4 56.72 56.72 47.27 47.27 E 37.23 37.23 united health care hmo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care ppo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care pos Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care hmo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care epo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 53.98 53.98 united health care hmo Stool culture cpt 87045 199.09 199.09 8.4 8.4 303.37 303.37 252.81 252.81 E 199.09 199.09 united health care ppo Stool culture cpt 87045 199.09 199.09 8.4 8.4 303.37 303.37 252.81 252.81 E 199.09 199.09 united health care pos Stool culture cpt 87045 199.09 199.09 8.4 8.4 303.37 303.37 252.81 252.81 E 199.09 199.09 united health care hmo Stool culture cpt 87045 199.09 199.09 8.4 8.4 303.37 303.37 252.81 252.81 E 199.09 199.09 united health care epo Stool culture cpt 87045 199.09 199.09 8.4 8.4 303.37 303.37 252.81 252.81 E 199.09 199.09 united health care hmo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 159.29 159.29 united health care ppo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 159.29 159.29 united health care pos Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 159.29 159.29 united health care hmo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 159.29 159.29 united health care epo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 159.29 159.29 united health care hmo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 179.68 179.68 united health care ppo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 179.68 179.68 united health care pos Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 179.68 179.68 united health care hmo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 179.68 179.68 united health care epo Bacterial blood culture cpt 87040 179.68 179.68 9.18 9.18 264.6 264.6 220.5 220.5 O 179.68 179.68 united health care hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 51283.25 51283.25 united health care ppo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 51283.25 51283.25 united health care pos Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 51283.25 51283.25 united health care hmo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 51283.25 51283.25 united health care epo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 51283.25 51283.25 united health care hmo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 1366.61 1366.61 united health care ppo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 1366.61 1366.61 united health care pos Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 1366.61 1366.61 united health care hmo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 1366.61 1366.61 united health care epo Design and construction of device for radiation therapy cpt 77338 1366.61 1366.61 292.16 292.16 2186.57 2186.57 1822.14 1822.14 O 1366.61 1366.61 united health care hmo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 91.53 91.53 united health care ppo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 91.53 91.53 united health care pos Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 91.53 91.53 united health care hmo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 91.53 91.53 united health care epo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 91.53 91.53 united health care hmo Radiation therapy consultation cpt 77370 298.92 298.92 110.46 110.46 478.27 478.27 398.56 398.56 O 298.92 298.92 united health care ppo Radiation therapy consultation cpt 77370 298.92 298.92 110.46 110.46 478.27 478.27 398.56 398.56 O 298.92 298.92 united health care pos Radiation therapy consultation cpt 77370 298.92 298.92 110.46 110.46 478.27 478.27 398.56 398.56 O 298.92 298.92 united health care hmo Radiation therapy consultation cpt 77370 298.92 298.92 110.46 110.46 478.27 478.27 398.56 398.56 O 298.92 298.92 united health care epo Radiation therapy consultation cpt 77370 298.92 298.92 110.46 110.46 478.27 478.27 398.56 398.56 O 298.92 298.92 united health care hmo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 9709.02 9709.02 united health care ppo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 9709.02 9709.02 united health care pos C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 9709.02 9709.02 united health care hmo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 9709.02 9709.02 united health care epo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 9709.02 9709.02 united health care hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 27.03 27.03 united health care ppo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 27.03 27.03 united health care pos Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 27.03 27.03 united health care hmo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 27.03 27.03 united health care epo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 27.03 27.03 united health care hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 264.62 264.62 united health care ppo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 264.62 264.62 united health care pos "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 264.62 264.62 united health care hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 264.62 264.62 united health care epo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 O 264.62 264.62 united health care hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 7062.19 7062.19 united health care ppo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 7062.19 7062.19 united health care pos Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 7062.19 7062.19 united health care hmo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 7062.19 7062.19 united health care epo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 7062.19 7062.19 united health care hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 264.62 264.62 united health care ppo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 264.62 264.62 united health care pos "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 264.62 264.62 united health care hmo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 264.62 264.62 united health care epo "Blood unit compatibility test, immediate spin technique" cpt 86920 264.62 264.62 14.05 14.05 403.22 403.22 336.02 336.02 E 264.62 264.62 united health care hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 56.45 56.45 united health care ppo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 56.45 56.45 united health care pos Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 56.45 56.45 united health care hmo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 56.45 56.45 united health care epo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 56.45 56.45 united health care hmo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 57.86 57.86 united health care ppo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 57.86 57.86 united health care pos Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 57.86 57.86 united health care hmo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 57.86 57.86 united health care epo Blood typing for Rh (D) antigen cpt 86901 57.86 57.86 2.66 2.66 90.31 90.31 75.26 75.26 E 57.86 57.86 united health care hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1605.9 1605.9 united health care ppo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1605.9 1605.9 united health care pos "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1605.9 1605.9 united health care hmo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1605.9 1605.9 united health care epo "Intensity modulated radiation therapy delivery, complex" cpt 77386 1605.9 1605.9 436.02 436.02 2569.44 2569.44 2141.2 2141.2 O 1605.9 1605.9 united health care hmo dental and oral diseases with cc ms-drg 158 9311.37 9311.37 3170.15 3170.15 23073.84 23073.84 19228.2 19228.2 I 9311.37 9311.37 united health care ppo dental and oral diseases with cc ms-drg 158 9311.37 9311.37 3170.15 3170.15 23073.84 23073.84 19228.2 19228.2 I 9311.37 9311.37 united health care pos dental and oral diseases with cc ms-drg 158 9311.37 9311.37 3170.15 3170.15 23073.84 23073.84 19228.2 19228.2 I 9311.37 9311.37 united health care hmo dental and oral diseases with cc ms-drg 158 9311.37 9311.37 3170.15 3170.15 23073.84 23073.84 19228.2 19228.2 I 9311.37 9311.37 united health care epo dental and oral diseases with cc ms-drg 158 9311.37 9311.37 3170.15 3170.15 23073.84 23073.84 19228.2 19228.2 I 9311.37 9311.37 united health care hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care hmo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 199.55 199.55 united health care ppo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 199.55 199.55 united health care pos Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 199.55 199.55 united health care hmo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 199.55 199.55 united health care epo Guidance for localization of target delivery of radiation treatment cpt 77387 199.55 199.55 155.94 155.94 319.27 319.27 266.06 266.06 O 199.55 199.55 united health care hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 87.2 87.2 united health care ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 87.2 87.2 united health care pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 87.2 87.2 united health care hmo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 87.2 87.2 united health care epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 E 87.2 87.2 united health care hmo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 99.45 99.45 united health care ppo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 99.45 99.45 united health care pos Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 99.45 99.45 united health care hmo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 99.45 99.45 united health care epo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 99.45 99.45 united health care hmo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 297.33 297.33 united health care ppo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 297.33 297.33 united health care pos "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 297.33 297.33 united health care hmo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 297.33 297.33 united health care epo "Red blood cell antibody detection test, direct" cpt 86880 297.33 297.33 4.79 4.79 475.73 475.73 396.44 396.44 O 297.33 297.33 united health care hmo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care ppo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care pos Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care hmo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care epo Stool lactoferrin (immune system protein) analysis cpt 83630 46.91 46.91 10.83 10.83 75.05 75.05 62.54 62.54 O 46.91 46.91 united health care hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 62.81 62.81 united health care ppo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 62.81 62.81 united health care pos Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 62.81 62.81 united health care hmo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 62.81 62.81 united health care epo Screening test for red blood cell antibodies cpt 86850 78 78 8.69 8.69 100.49 100.49 83.74 83.74 O 62.81 62.81 united health care hmo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 65.94 65.94 united health care ppo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 65.94 65.94 united health care pos Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 65.94 65.94 united health care hmo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 65.94 65.94 united health care epo Screening test for red blood cell antibodies cpt 86850 65.94 65.94 8.69 8.69 100.49 100.49 83.74 83.74 E 65.94 65.94 united health care hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 628.85 628.85 united health care ppo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 628.85 628.85 united health care pos "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 628.85 628.85 united health care hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 628.85 628.85 united health care epo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 628.85 628.85 united health care hmo other antepartum diagnoses without o.r. procedures with cc ms-drg 832 7684.4 7684.4 1960.72 1960.72 12643.03 12643.03 10535.86 10535.86 I 7684.4 7684.4 united health care ppo other antepartum diagnoses without o.r. procedures with cc ms-drg 832 7684.4 7684.4 1960.72 1960.72 12643.03 12643.03 10535.86 10535.86 I 7684.4 7684.4 united health care pos other antepartum diagnoses without o.r. procedures with cc ms-drg 832 7684.4 7684.4 1960.72 1960.72 12643.03 12643.03 10535.86 10535.86 I 7684.4 7684.4 united health care hmo other antepartum diagnoses without o.r. procedures with cc ms-drg 832 7684.4 7684.4 1960.72 1960.72 12643.03 12643.03 10535.86 10535.86 I 7684.4 7684.4 united health care epo other antepartum diagnoses without o.r. procedures with cc ms-drg 832 7684.4 7684.4 1960.72 1960.72 12643.03 12643.03 10535.86 10535.86 I 7684.4 7684.4 united health care hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 76.32 76.32 united health care ppo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 76.32 76.32 united health care pos Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 76.32 76.32 united health care hmo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 76.32 76.32 united health care epo Lactate dehydrogenase (enzyme) level cpt 83615 76.32 76.32 5.37 5.37 115.2 115.2 96 96 O 76.32 76.32 united health care hmo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 76.32 76.32 united health care ppo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 76.32 76.32 united health care pos Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 76.32 76.32 united health care hmo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 76.32 76.32 united health care epo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 76.32 76.32 united health care hmo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care ppo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care pos Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care hmo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care epo Therapeutic radiology port films cpt 77417 27.03 27.03 26.53 26.53 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care hmo Special radiation treatment procedure cpt 77470 469.7 469.7 423.74 423.74 677.98 677.98 564.98 564.98 O 423.74 423.74 united health care ppo Special radiation treatment procedure cpt 77470 469.7 469.7 423.74 423.74 677.98 677.98 564.98 564.98 O 423.74 423.74 united health care pos Special radiation treatment procedure cpt 77470 469.7 469.7 423.74 423.74 677.98 677.98 564.98 564.98 O 423.74 423.74 united health care hmo Special radiation treatment procedure cpt 77470 469.7 469.7 423.74 423.74 677.98 677.98 564.98 564.98 O 423.74 423.74 united health care epo Special radiation treatment procedure cpt 77470 469.7 469.7 423.74 423.74 677.98 677.98 564.98 564.98 O 423.74 423.74 united health care hmo Removal (3 centimeters or greater) tissue growth beneath the skin of thigh or knee cpt 27337 11844.5 11844.5 11844.5 11844.5 18951.19 18951.19 15792.66 15792.66 O 11844.5 11844.5 united health care ppo Removal (3 centimeters or greater) tissue growth beneath the skin of thigh or knee cpt 27337 11844.5 11844.5 11844.5 11844.5 18951.19 18951.19 15792.66 15792.66 O 11844.5 11844.5 united health care pos Removal (3 centimeters or greater) tissue growth beneath the skin of thigh or knee cpt 27337 11844.5 11844.5 11844.5 11844.5 18951.19 18951.19 15792.66 15792.66 O 11844.5 11844.5 united health care hmo Removal (3 centimeters or greater) tissue growth beneath the skin of thigh or knee cpt 27337 11844.5 11844.5 11844.5 11844.5 18951.19 18951.19 15792.66 15792.66 O 11844.5 11844.5 united health care epo Removal (3 centimeters or greater) tissue growth beneath the skin of thigh or knee cpt 27337 11844.5 11844.5 11844.5 11844.5 18951.19 18951.19 15792.66 15792.66 O 11844.5 11844.5 united health care hmo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 50.92 50.92 united health care ppo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 50.92 50.92 united health care pos Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 50.92 50.92 united health care hmo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 50.92 50.92 united health care epo Thyroglobulin (thyroid protein) antibody measurement cpt 86800 50.92 50.92 14.15 14.15 77.59 77.59 64.66 64.66 O 50.92 50.92 united health care hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 46.06 46.06 united health care ppo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 46.06 46.06 united health care pos Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 46.06 46.06 united health care hmo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 46.06 46.06 united health care epo Creatinine level to test for kidney function or muscle injury cpt 82570 48.76 48.76 4.61 4.61 53.93 53.93 44.94 44.94 O 46.06 46.06 united health care hmo "High dose brachytherapy , 2- 12 channels" cpt 77771 1543.89 1543.89 645.51 645.51 2470.22 2470.22 2058.52 2058.52 O 1543.89 1543.89 united health care ppo "High dose brachytherapy , 2- 12 channels" cpt 77771 1543.89 1543.89 645.51 645.51 2470.22 2470.22 2058.52 2058.52 O 1543.89 1543.89 united health care pos "High dose brachytherapy , 2- 12 channels" cpt 77771 1543.89 1543.89 645.51 645.51 2470.22 2470.22 2058.52 2058.52 O 1543.89 1543.89 united health care hmo "High dose brachytherapy , 2- 12 channels" cpt 77771 1543.89 1543.89 645.51 645.51 2470.22 2470.22 2058.52 2058.52 O 1543.89 1543.89 united health care epo "High dose brachytherapy , 2- 12 channels" cpt 77771 1543.89 1543.89 645.51 645.51 2470.22 2470.22 2058.52 2058.52 O 1543.89 1543.89 united health care hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 35.78 35.78 united health care ppo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 35.78 35.78 united health care pos Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 35.78 35.78 united health care hmo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 35.78 35.78 united health care epo Analysis for antibody to varicella-zoster virus (chicken pox) cpt 86787 35.78 35.78 7.94 7.94 57.24 57.24 47.7 47.7 O 35.78 35.78 united health care hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 1030.32 1030.32 united health care ppo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 1030.32 1030.32 united health care pos Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 1030.32 1030.32 united health care hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 1030.32 1030.32 united health care epo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 1030.32 1030.32 united health care hmo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 25102.09 25102.09 united health care ppo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 25102.09 25102.09 united health care pos chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 25102.09 25102.09 united health care hmo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 25102.09 25102.09 united health care epo chronic obstructive pulmonary disease without cc/mcc ms-drg 192 25102.09 25102.09 3596.24 3596.24 15877.78 15877.78 13231.48 13231.48 I 25102.09 25102.09 united health care hmo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 1368.2 1368.2 united health care ppo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 1368.2 1368.2 united health care pos "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 1368.2 1368.2 united health care hmo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 1368.2 1368.2 united health care epo "Bone and/or joint imaging, 3 phase study" cpt 78315 1368.2 1368.2 253.85 253.85 2189.11 2189.11 1824.26 1824.26 O 1368.2 1368.2 united health care hmo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 25007.97 25007.97 united health care ppo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 25007.97 25007.97 united health care pos simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 25007.97 25007.97 united health care hmo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 25007.97 25007.97 united health care epo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 25007.97 25007.97 united health care hmo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.71 33.71 united health care ppo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.71 33.71 united health care pos Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.71 33.71 united health care hmo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.71 33.71 united health care epo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.71 33.71 united health care hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 3752.4 3752.4 united health care ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 3752.4 3752.4 united health care pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 3752.4 3752.4 united health care hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 3752.4 3752.4 united health care epo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 5253.36 5253.36 334.96 334.96 6003.84 6003.84 5003.2 5003.2 E 3752.4 3752.4 united health care hmo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 48.5 48.5 united health care ppo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 48.5 48.5 united health care pos Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 48.5 48.5 united health care hmo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 48.5 48.5 united health care epo Lactic acid level cpt 83605 64.66 64.66 10.29 10.29 76.32 76.32 63.6 63.6 O 48.5 48.5 united health care hmo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 63.6 63.6 united health care ppo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 63.6 63.6 united health care pos Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 63.6 63.6 united health care hmo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 63.6 63.6 united health care epo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 63.6 63.6 united health care hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 3752.4 3752.4 united health care ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 3752.4 3752.4 united health care pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 3752.4 3752.4 united health care hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 3752.4 3752.4 united health care epo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 3752.4 3752.4 united health care hmo Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 106.53 106.53 united health care ppo Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 106.53 106.53 united health care pos Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 106.53 106.53 united health care hmo Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 106.53 106.53 united health care epo Blood gases measurement cpt 82803 142.04 142.04 23.19 23.19 170.45 170.45 142.04 142.04 E 106.53 106.53 united health care hmo Removal (1.5 centimeters or greater) tissue beneath the skin growth of hand or finger cpt 26111 11689.03 11689.03 11689.03 11689.03 18702.44 18702.44 15585.37 15585.37 O 11689.03 11689.03 united health care ppo Removal (1.5 centimeters or greater) tissue beneath the skin growth of hand or finger cpt 26111 11689.03 11689.03 11689.03 11689.03 18702.44 18702.44 15585.37 15585.37 O 11689.03 11689.03 united health care pos Removal (1.5 centimeters or greater) tissue beneath the skin growth of hand or finger cpt 26111 11689.03 11689.03 11689.03 11689.03 18702.44 18702.44 15585.37 15585.37 O 11689.03 11689.03 united health care hmo Removal (1.5 centimeters or greater) tissue beneath the skin growth of hand or finger cpt 26111 11689.03 11689.03 11689.03 11689.03 18702.44 18702.44 15585.37 15585.37 O 11689.03 11689.03 united health care epo Removal (1.5 centimeters or greater) tissue beneath the skin growth of hand or finger cpt 26111 11689.03 11689.03 11689.03 11689.03 18702.44 18702.44 15585.37 15585.37 O 11689.03 11689.03 united health care hmo pneumothorax with cc ms-drg 200 22906.66 22906.66 4418.11 4418.11 25021.14 25021.14 20850.95 20850.95 I 22906.66 22906.66 united health care ppo pneumothorax with cc ms-drg 200 22906.66 22906.66 4418.11 4418.11 25021.14 25021.14 20850.95 20850.95 I 22906.66 22906.66 united health care pos pneumothorax with cc ms-drg 200 22906.66 22906.66 4418.11 4418.11 25021.14 25021.14 20850.95 20850.95 I 22906.66 22906.66 united health care hmo pneumothorax with cc ms-drg 200 22906.66 22906.66 4418.11 4418.11 25021.14 25021.14 20850.95 20850.95 I 22906.66 22906.66 united health care epo pneumothorax with cc ms-drg 200 22906.66 22906.66 4418.11 4418.11 25021.14 25021.14 20850.95 20850.95 I 22906.66 22906.66 united health care hmo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 13719.01 13719.01 united health care ppo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 13719.01 13719.01 united health care pos Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 13719.01 13719.01 united health care hmo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 13719.01 13719.01 united health care epo Incision of tendon covering cpt 26055 13719.01 13719.01 1097.92 1097.92 17011.03 17011.03 14175.86 14175.86 O 13719.01 13719.01 united health care hmo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 118.85 118.85 united health care ppo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 118.85 118.85 united health care pos Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 118.85 118.85 united health care hmo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 118.85 118.85 united health care epo Hepatitis B core antibody measurement cpt 86704 118.85 118.85 10.72 10.72 190.16 190.16 158.47 158.47 O 118.85 118.85 united health care hmo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 204.66 204.66 united health care ppo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 204.66 204.66 united health care pos "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 204.66 204.66 united health care hmo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 204.66 204.66 united health care epo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 204.66 204.66 united health care hmo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 48.5 48.5 united health care ppo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 48.5 48.5 united health care pos Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 48.5 48.5 united health care hmo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 48.5 48.5 united health care epo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 48.5 48.5 united health care hmo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 55.4 55.4 united health care ppo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 55.4 55.4 united health care pos "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 55.4 55.4 united health care hmo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 55.4 55.4 united health care epo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 55.4 55.4 united health care hmo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 173837.62 173837.62 united health care ppo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 173837.62 173837.62 united health care pos respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 173837.62 173837.62 united health care hmo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 173837.62 173837.62 united health care epo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 173837.62 173837.62 united health care hmo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 2311.63 2311.63 united health care ppo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 2311.63 2311.63 united health care pos Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 2311.63 2311.63 united health care hmo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 2311.63 2311.63 united health care epo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 2311.63 2311.63 united health care hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 71.63 71.63 united health care ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 71.63 71.63 united health care pos Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 71.63 71.63 united health care hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 71.63 71.63 united health care epo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 71.63 71.63 united health care hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4915.33 4915.33 united health care ppo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4915.33 4915.33 united health care pos Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4915.33 4915.33 united health care hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4915.33 4915.33 united health care epo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 4915.33 4915.33 united health care hmo coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 141718.36 141718.36 united health care ppo coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 141718.36 141718.36 united health care pos coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 141718.36 141718.36 united health care hmo coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 141718.36 141718.36 united health care epo coronary bypass with cardiac catheterization with mcc ms-drg 233 141718.36 141718.36 28603.68 28603.68 234499.09 234499.09 195415.91 195415.91 I 141718.36 141718.36 united health care hmo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care ppo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care pos Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care hmo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care epo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 27.03 27.03 united health care hmo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 112527.02 112527.02 united health care ppo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 112527.02 112527.02 united health care pos coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 112527.02 112527.02 united health care hmo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 112527.02 112527.02 united health care epo coronary bypass with cardiac catheterization without mcc ms-drg 234 112527.02 112527.02 25784.61 25784.61 201221.45 201221.45 167684.54 167684.54 I 112527.02 112527.02 united health care hmo General health panel cpt 80050 531.61 531.61 531.61 531.61 850.57 850.57 708.81 708.81 E 531.61 531.61 united health care ppo General health panel cpt 80050 531.61 531.61 531.61 531.61 850.57 850.57 708.81 708.81 E 531.61 531.61 united health care pos General health panel cpt 80050 531.61 531.61 531.61 531.61 850.57 850.57 708.81 708.81 E 531.61 531.61 united health care hmo General health panel cpt 80050 531.61 531.61 531.61 531.61 850.57 850.57 708.81 708.81 E 531.61 531.61 united health care epo General health panel cpt 80050 531.61 531.61 531.61 531.61 850.57 850.57 708.81 708.81 E 531.61 531.61 united health care hmo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 104057.01 104057.01 united health care ppo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 104057.01 104057.01 united health care pos coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 104057.01 104057.01 united health care hmo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 104057.01 104057.01 united health care epo coronary bypass without cardiac catheterization without mcc ms-drg 236 104057.01 104057.01 21785.45 21785.45 127740.22 127740.22 106450.18 106450.18 I 104057.01 104057.01 united health care hmo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 54.06 54.06 united health care ppo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 54.06 54.06 united health care pos Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 54.06 54.06 united health care hmo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 54.06 54.06 united health care epo Creatinine clearance measurement to test for kidney function cpt 82575 54.06 54.06 8.41 8.41 151.37 151.37 126.14 126.14 O 54.06 54.06 united health care hmo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 202.48 202.48 united health care ppo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 202.48 202.48 united health care pos General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 202.48 202.48 united health care hmo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 202.48 202.48 united health care epo General health panel cpt 80050 202.48 202.48 22.42 22.42 323.96 323.96 269.97 269.97 O 202.48 202.48 united health care hmo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 106.53 106.53 united health care ppo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 106.53 106.53 united health care pos Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 106.53 106.53 united health care hmo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 106.53 106.53 united health care epo Blood gases measurement cpt 82803 106.53 106.53 23.19 23.19 170.45 170.45 142.04 142.04 O 106.53 106.53 united health care hmo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 48586.64 48586.64 united health care ppo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 48586.64 48586.64 united health care pos percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 48586.64 48586.64 united health care hmo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 48586.64 48586.64 united health care epo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 48586.64 48586.64 united health care hmo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 236.12 236.12 united health care ppo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 236.12 236.12 united health care pos "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 236.12 236.12 united health care hmo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 236.12 236.12 united health care epo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 236.12 236.12 united health care hmo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care ppo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care pos Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care hmo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care epo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52876.69 52876.69 united health care ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52876.69 52876.69 united health care pos percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52876.69 52876.69 united health care hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52876.69 52876.69 united health care epo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 52876.69 52876.69 united health care hmo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 37.36 37.36 united health care ppo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 37.36 37.36 united health care pos Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 37.36 37.36 united health care hmo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 37.36 37.36 united health care epo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 37.36 37.36 united health care hmo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 67.61 67.61 united health care ppo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 67.61 67.61 united health care pos Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 67.61 67.61 united health care hmo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 67.61 67.61 united health care epo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 67.61 67.61 united health care hmo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 68604.42 68604.42 united health care ppo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 68604.42 68604.42 united health care pos infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 68604.42 68604.42 united health care hmo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 68604.42 68604.42 united health care epo infectious and parasitic diseases with o.r. procedures with mcc ms-drg 853 85704.11 85704.11 953.05 953.05 121357.7 121357.7 101131.42 101131.42 I 68604.42 68604.42 united health care hmo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 29670.79 29670.79 united health care ppo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 29670.79 29670.79 united health care pos infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 29670.79 29670.79 united health care hmo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 29670.79 29670.79 united health care epo infectious and parasitic diseases with o.r. procedures with cc ms-drg 854 29670.79 29670.79 10706.37 10706.37 60009.55 60009.55 50007.96 50007.96 I 29670.79 29670.79 united health care hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 58.67 58.67 united health care ppo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 58.67 58.67 united health care pos Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 58.67 58.67 united health care hmo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 58.67 58.67 united health care epo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 58.67 58.67 united health care hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care pos Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care epo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 27.83 27.83 united health care hmo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 144.13 144.13 united health care ppo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 144.13 144.13 united health care pos Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 144.13 144.13 united health care hmo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 144.13 144.13 united health care epo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 144.13 144.13 united health care hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 71.78 71.78 united health care ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 71.78 71.78 united health care pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 71.78 71.78 united health care hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 71.78 71.78 united health care epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" cpt 86301 79.34 79.34 18.51 18.51 109.39 109.39 91.16 91.16 O 71.78 71.78 united health care hmo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 24078.21 24078.21 united health care ppo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 24078.21 24078.21 united health care pos "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 24078.21 24078.21 united health care hmo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 24078.21 24078.21 united health care epo "acute myocardial infarction, discharged alive without cc/mcc" ms-drg 282 24078.21 24078.21 5315.78 5315.78 40450.2 40450.2 33708.5 33708.5 I 24078.21 24078.21 united health care hmo postoperative or post-traumatic infections with o.r. procedures with mcc ms-drg 856 65295.34 65295.34 23364.17 23364.17 104472.54 104472.54 87060.45 87060.45 I 65295.34 65295.34 united health care ppo postoperative or post-traumatic infections with o.r. procedures with mcc ms-drg 856 65295.34 65295.34 23364.17 23364.17 104472.54 104472.54 87060.45 87060.45 I 65295.34 65295.34 united health care pos postoperative or post-traumatic infections with o.r. procedures with mcc ms-drg 856 65295.34 65295.34 23364.17 23364.17 104472.54 104472.54 87060.45 87060.45 I 65295.34 65295.34 united health care hmo postoperative or post-traumatic infections with o.r. procedures with mcc ms-drg 856 65295.34 65295.34 23364.17 23364.17 104472.54 104472.54 87060.45 87060.45 I 65295.34 65295.34 united health care epo postoperative or post-traumatic infections with o.r. procedures with mcc ms-drg 856 65295.34 65295.34 23364.17 23364.17 104472.54 104472.54 87060.45 87060.45 I 65295.34 65295.34 united health care hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 165.17 165.17 united health care ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 165.17 165.17 united health care pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 165.17 165.17 united health care hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 165.17 165.17 united health care epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 165.17 165.17 united health care hmo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 20454.64 20454.64 united health care ppo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 20454.64 20454.64 united health care pos "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 20454.64 20454.64 united health care hmo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 20454.64 20454.64 united health care epo "circulatory disorders except ami, with cardiac catheterization without mcc" ms-drg 287 20454.64 20454.64 6355.08 6355.08 40015 40015 33345.83 33345.83 I 20454.64 20454.64 united health care hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 61.22 61.22 united health care ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 61.22 61.22 united health care pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 61.22 61.22 united health care hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 61.22 61.22 united health care epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 61.22 61.22 united health care hmo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 29.53 29.53 united health care ppo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 29.53 29.53 united health care pos "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 29.53 29.53 united health care hmo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 29.53 29.53 united health care epo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 29.53 29.53 united health care hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 21478.52 21478.52 united health care ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 21478.52 21478.52 united health care pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 21478.52 21478.52 united health care hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 21478.52 21478.52 united health care epo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 21478.52 21478.52 united health care hmo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 107.33 107.33 united health care ppo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 107.33 107.33 united health care pos "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 107.33 107.33 united health care hmo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 107.33 107.33 united health care epo "Phenytoin level, total" cpt 80185 150.25 150.25 12.98 12.98 117.02 117.02 97.52 97.52 O 107.33 107.33 united health care hmo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 15968.17 15968.17 united health care ppo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 15968.17 15968.17 united health care pos postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 15968.17 15968.17 united health care hmo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 15968.17 15968.17 united health care epo postoperative and post-traumatic infections with mcc ms-drg 862 26149.85 26149.85 9402.85 9402.85 33753.85 33753.85 28128.21 28128.21 I 15968.17 15968.17 united health care hmo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 169.34 169.34 united health care ppo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 169.34 169.34 united health care pos Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 169.34 169.34 united health care hmo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 169.34 169.34 united health care epo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 169.34 169.34 united health care hmo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 22045.55 22045.55 united health care ppo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 22045.55 22045.55 united health care pos heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 22045.55 22045.55 united health care hmo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 22045.55 22045.55 united health care epo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 22045.55 22045.55 united health care hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 170.29 170.29 united health care ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 170.29 170.29 united health care pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 170.29 170.29 united health care hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 170.29 170.29 united health care epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 170.29 170.29 united health care hmo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 173.57 173.57 united health care ppo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 173.57 173.57 united health care pos "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 173.57 173.57 united health care hmo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 173.57 173.57 united health care epo "X-ray of middle and lower spine, 2 views" cpt 72080 173.57 173.57 18.96 18.96 270.94 270.94 225.78 225.78 O 173.57 173.57 united health care hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 49.58 49.58 united health care ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 49.58 49.58 united health care pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 49.58 49.58 united health care hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 49.58 49.58 united health care epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 49.58 49.58 united health care hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 united health care ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 united health care pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 united health care hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 united health care epo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 193.82 193.82 united health care hmo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 1368.51 1368.51 united health care ppo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 1368.51 1368.51 united health care pos "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 1368.51 1368.51 united health care hmo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 1368.51 1368.51 united health care epo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 1368.51 1368.51 united health care hmo heart failure and shock without cc/mcc ms-drg 293 9035.93 9035.93 2941.69 2941.69 15739.96 15739.96 13116.63 13116.63 I 9035.93 9035.93 united health care ppo heart failure and shock without cc/mcc ms-drg 293 9035.93 9035.93 2941.69 2941.69 15739.96 15739.96 13116.63 13116.63 I 9035.93 9035.93 united health care pos heart failure and shock without cc/mcc ms-drg 293 9035.93 9035.93 2941.69 2941.69 15739.96 15739.96 13116.63 13116.63 I 9035.93 9035.93 united health care hmo heart failure and shock without cc/mcc ms-drg 293 9035.93 9035.93 2941.69 2941.69 15739.96 15739.96 13116.63 13116.63 I 9035.93 9035.93 united health care epo heart failure and shock without cc/mcc ms-drg 293 9035.93 9035.93 2941.69 2941.69 15739.96 15739.96 13116.63 13116.63 I 9035.93 9035.93 united health care hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care epo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care hmo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 222.6 222.6 united health care ppo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 222.6 222.6 united health care pos Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 222.6 222.6 united health care hmo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 222.6 222.6 united health care epo Cardiolipin antibody (tissue antibody) measurement cpt 86147 222.6 222.6 22.64 22.64 356.16 356.16 296.8 296.8 O 222.6 222.6 united health care hmo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 6873.58 6873.58 united health care ppo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 6873.58 6873.58 united health care pos "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 6873.58 6873.58 united health care hmo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 6873.58 6873.58 united health care epo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 6873.58 6873.58 united health care hmo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 54.6 54.6 united health care ppo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 54.6 54.6 united health care pos "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 54.6 54.6 united health care hmo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 54.6 54.6 united health care epo "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" cpt 86141 54.6 54.6 10.31 10.31 149.16 149.16 124.3 124.3 O 54.6 54.6 united health care hmo "X-ray of middle spine, 3 views" cpt 72072 243.94 243.94 21.37 21.37 384.14 384.14 320.12 320.12 E 243.94 243.94 united health care ppo "X-ray of middle spine, 3 views" cpt 72072 243.94 243.94 21.37 21.37 384.14 384.14 320.12 320.12 E 243.94 243.94 united health care pos "X-ray of middle spine, 3 views" cpt 72072 243.94 243.94 21.37 21.37 384.14 384.14 320.12 320.12 E 243.94 243.94 united health care hmo "X-ray of middle spine, 3 views" cpt 72072 243.94 243.94 21.37 21.37 384.14 384.14 320.12 320.12 E 243.94 243.94 united health care epo "X-ray of middle spine, 3 views" cpt 72072 243.94 243.94 21.37 21.37 384.14 384.14 320.12 320.12 E 243.94 243.94 united health care hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 274.63 274.63 united health care ppo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 274.63 274.63 united health care pos "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 274.63 274.63 united health care hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 274.63 274.63 united health care epo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 274.63 274.63 21.37 21.37 418.49 418.49 348.74 348.74 E 274.63 274.63 united health care hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 268.09 268.09 united health care ppo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 268.09 268.09 united health care pos "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 268.09 268.09 united health care hmo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 268.09 268.09 united health care epo "X-ray of lower and sacral spine, 2 or 3 views" cpt 72100 268.09 268.09 21.37 21.37 418.49 418.49 348.74 348.74 O 268.09 268.09 united health care hmo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 3814.04 3814.04 united health care ppo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 3814.04 3814.04 united health care pos Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 3814.04 3814.04 united health care hmo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 3814.04 3814.04 united health care epo Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare cpt 45385 3814.04 3814.04 1237.74 1237.74 6150.4 6150.4 5125.33 5125.33 O 3814.04 3814.04 united health care hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 339.55 339.55 united health care ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 339.55 339.55 united health care pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 339.55 339.55 united health care hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 339.55 339.55 united health care epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 339.55 339.55 11.91 11.91 460.1 460.1 383.42 383.42 E 339.55 339.55 united health care hmo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 415.7 415.7 united health care ppo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 415.7 415.7 united health care pos "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 415.7 415.7 united health care hmo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 415.7 415.7 united health care epo "X-ray of upper spine, 6 or more views" cpt 72052 415.7 415.7 35.2 35.2 633.46 633.46 527.88 527.88 O 415.7 415.7 united health care hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 3589.03 3589.03 united health care ppo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 3589.03 3589.03 united health care pos Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 3589.03 3589.03 united health care hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 3589.03 3589.03 united health care epo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 3589.03 3589.03 united health care hmo hiv with major related condition without cc/mcc ms-drg 976 17984.05 17984.05 17984.05 17984.05 28774.48 28774.48 23978.73 23978.73 I 17984.05 17984.05 united health care ppo hiv with major related condition without cc/mcc ms-drg 976 17984.05 17984.05 17984.05 17984.05 28774.48 28774.48 23978.73 23978.73 I 17984.05 17984.05 united health care pos hiv with major related condition without cc/mcc ms-drg 976 17984.05 17984.05 17984.05 17984.05 28774.48 28774.48 23978.73 23978.73 I 17984.05 17984.05 united health care hmo hiv with major related condition without cc/mcc ms-drg 976 17984.05 17984.05 17984.05 17984.05 28774.48 28774.48 23978.73 23978.73 I 17984.05 17984.05 united health care epo hiv with major related condition without cc/mcc ms-drg 976 17984.05 17984.05 17984.05 17984.05 28774.48 28774.48 23978.73 23978.73 I 17984.05 17984.05 united health care hmo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 575.98 575.98 united health care ppo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 575.98 575.98 united health care pos X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 575.98 575.98 united health care hmo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 575.98 575.98 united health care epo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 575.98 575.98 united health care hmo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 13381.81 13381.81 united health care ppo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 13381.81 13381.81 united health care pos hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 13381.81 13381.81 united health care hmo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 13381.81 13381.81 united health care epo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 13381.81 13381.81 united health care hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 102.07 102.07 united health care ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 102.07 102.07 united health care pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 102.07 102.07 united health care hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 102.07 102.07 united health care epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 102.07 102.07 united health care hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 2708.94 2708.94 united health care ppo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 2708.94 2708.94 united health care pos Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 2708.94 2708.94 united health care hmo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 2708.94 2708.94 united health care epo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 2708.94 2708.94 united health care hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 45.55 45.55 united health care ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 45.55 45.55 united health care pos Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 45.55 45.55 united health care hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 45.55 45.55 united health care epo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 45.55 45.55 united health care hmo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care ppo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care pos Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care hmo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care epo Kidney function blood test panel cpt 80069 47.82 47.82 7.72 7.72 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2918.38 2918.38 united health care ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2918.38 2918.38 united health care pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2918.38 2918.38 united health care hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2918.38 2918.38 united health care epo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2918.38 2918.38 united health care hmo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 413.4 413.4 united health care ppo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 413.4 413.4 united health care pos "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 413.4 413.4 united health care hmo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 413.4 413.4 united health care epo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 413.4 413.4 united health care hmo Fine needle aspiration of first lesion using CT guidance cpt 10009 5239.66 5239.66 531.75 531.75 8383.45 8383.45 6986.21 6986.21 O 5239.66 5239.66 united health care ppo Fine needle aspiration of first lesion using CT guidance cpt 10009 5239.66 5239.66 531.75 531.75 8383.45 8383.45 6986.21 6986.21 O 5239.66 5239.66 united health care pos Fine needle aspiration of first lesion using CT guidance cpt 10009 5239.66 5239.66 531.75 531.75 8383.45 8383.45 6986.21 6986.21 O 5239.66 5239.66 united health care hmo Fine needle aspiration of first lesion using CT guidance cpt 10009 5239.66 5239.66 531.75 531.75 8383.45 8383.45 6986.21 6986.21 O 5239.66 5239.66 united health care epo Fine needle aspiration of first lesion using CT guidance cpt 10009 5239.66 5239.66 531.75 531.75 8383.45 8383.45 6986.21 6986.21 O 5239.66 5239.66 united health care hmo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 1170.32 1170.32 united health care ppo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 1170.32 1170.32 united health care pos CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 1170.32 1170.32 united health care hmo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 1170.32 1170.32 united health care epo CT scan of upper spine cpt 72125 1170.32 1170.32 93.83 93.83 1783.34 1783.34 1486.12 1486.12 E 1170.32 1170.32 united health care hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 47.22 47.22 united health care ppo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 47.22 47.22 united health care pos Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 47.22 47.22 united health care hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 47.22 47.22 united health care epo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 47.22 47.22 united health care hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care ppo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care pos "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care epo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 61.53 61.53 united health care hmo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 1170.32 1170.32 united health care ppo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 1170.32 1170.32 united health care pos CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 1170.32 1170.32 united health care hmo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 1170.32 1170.32 united health care epo CT scan of upper spine cpt 72125 1170.32 1170.32 88.61 88.61 1783.34 1783.34 1486.12 1486.12 O 1170.32 1170.32 united health care hmo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 230.55 230.55 united health care ppo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 230.55 230.55 united health care pos "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 230.55 230.55 united health care hmo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 230.55 230.55 united health care epo "X-ray of spine of neck, 2 or 3 views" cpt 72040 230.55 230.55 22.45 22.45 368.88 368.88 307.4 307.4 O 230.55 230.55 united health care hmo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 27.03 27.03 united health care ppo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 27.03 27.03 united health care pos Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 27.03 27.03 united health care hmo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 27.03 27.03 united health care epo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 27.03 27.03 united health care hmo "X-ray of spine of neck, 2 or 3 views" cpt 72040 39.16 39.16 21.37 21.37 368.88 368.88 307.4 307.4 E 39.16 39.16 united health care ppo "X-ray of spine of neck, 2 or 3 views" cpt 72040 39.16 39.16 21.37 21.37 368.88 368.88 307.4 307.4 E 39.16 39.16 united health care pos "X-ray of spine of neck, 2 or 3 views" cpt 72040 39.16 39.16 21.37 21.37 368.88 368.88 307.4 307.4 E 39.16 39.16 united health care hmo "X-ray of spine of neck, 2 or 3 views" cpt 72040 39.16 39.16 21.37 21.37 368.88 368.88 307.4 307.4 E 39.16 39.16 united health care epo "X-ray of spine of neck, 2 or 3 views" cpt 72040 39.16 39.16 21.37 21.37 368.88 368.88 307.4 307.4 E 39.16 39.16 united health care hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 223.4 223.4 united health care ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 223.4 223.4 united health care pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 223.4 223.4 united health care hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 223.4 223.4 united health care epo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 223.4 223.4 united health care hmo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 190.01 190.01 united health care ppo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 190.01 190.01 united health care pos Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 190.01 190.01 united health care hmo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 190.01 190.01 united health care epo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 190.01 190.01 united health care hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.3 9.3 united health care ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.3 9.3 united health care pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.3 9.3 united health care hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.3 9.3 united health care epo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.3 9.3 united health care hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 4.61 4.61 72.88 72.88 60.73 60.73 E 45.55 45.55 united health care ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 4.61 4.61 72.88 72.88 60.73 60.73 E 45.55 45.55 united health care pos Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 4.61 4.61 72.88 72.88 60.73 60.73 E 45.55 45.55 united health care hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 4.61 4.61 72.88 72.88 60.73 60.73 E 45.55 45.55 united health care epo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 4.61 4.61 72.88 72.88 60.73 60.73 E 45.55 45.55 united health care hmo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 69.96 69.96 united health care ppo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 69.96 69.96 united health care pos "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 69.96 69.96 united health care hmo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 69.96 69.96 united health care epo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 69.96 69.96 united health care hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 187.42 187.42 united health care ppo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 187.42 187.42 united health care pos Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 187.42 187.42 united health care hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 187.42 187.42 united health care epo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 187.42 187.42 united health care hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5592.58 5592.58 united health care ppo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5592.58 5592.58 united health care pos cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5592.58 5592.58 united health care hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5592.58 5592.58 united health care epo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 5592.58 5592.58 united health care hmo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care ppo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care pos CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care hmo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care epo CT scan of blood vessels in chest with contrast cpt 71275 1195.68 1195.68 159.21 159.21 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 535.83 535.83 united health care ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 535.83 535.83 united health care pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 535.83 535.83 united health care hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 535.83 535.83 united health care epo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 535.83 535.83 united health care hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 81.09 81.09 united health care ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 81.09 81.09 united health care pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 81.09 81.09 united health care hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 81.09 81.09 united health care epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 81.09 81.09 united health care hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 535.83 535.83 united health care ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 535.83 535.83 united health care pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 535.83 535.83 united health care hmo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 535.83 535.83 united health care epo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 E 535.83 535.83 united health care hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 298.13 298.13 united health care ppo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 298.13 298.13 united health care pos Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 298.13 298.13 united health care hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 298.13 298.13 united health care epo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 298.13 298.13 united health care hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care pos MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care hmo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care epo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 511.19 511.19 90.7 90.7 817.9 817.9 681.58 681.58 E 511.19 511.19 united health care ppo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 511.19 511.19 90.7 90.7 817.9 817.9 681.58 681.58 E 511.19 511.19 united health care pos Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 511.19 511.19 90.7 90.7 817.9 817.9 681.58 681.58 E 511.19 511.19 united health care hmo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 511.19 511.19 90.7 90.7 817.9 817.9 681.58 681.58 E 511.19 511.19 united health care epo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 511.19 511.19 90.7 90.7 817.9 817.9 681.58 681.58 E 511.19 511.19 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 166.07 166.07 united health care ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 166.07 166.07 united health care pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 166.07 166.07 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 166.07 166.07 united health care epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 166.07 166.07 united health care hmo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 1225.57 1225.57 united health care ppo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 1225.57 1225.57 united health care pos CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 1225.57 1225.57 united health care hmo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 1225.57 1225.57 united health care epo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 1225.57 1225.57 united health care hmo "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care ppo "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care pos "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care hmo "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care epo "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 68.37 68.37 united health care hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 654.29 654.29 united health care ppo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 654.29 654.29 united health care pos "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 654.29 654.29 united health care hmo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 654.29 654.29 united health care epo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 654.29 654.29 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 59.86 59.86 united health care ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 59.86 59.86 united health care pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 59.86 59.86 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 59.86 59.86 united health care epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 59.86 59.86 united health care hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2285.63 2285.63 united health care ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2285.63 2285.63 united health care pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2285.63 2285.63 united health care hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2285.63 2285.63 united health care epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 2285.63 2285.63 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 96.11 96.11 united health care ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 96.11 96.11 united health care pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 96.11 96.11 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 96.11 96.11 united health care epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 96.11 96.11 5.75 5.75 153.78 153.78 128.15 128.15 E 96.11 96.11 united health care hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 372.86 372.86 united health care ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 372.86 372.86 united health care pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 372.86 372.86 united health care hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 372.86 372.86 united health care epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 521.99 521.99 15.25 15.25 596.57 596.57 497.14 497.14 E 372.86 372.86 united health care hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care pos CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care epo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 1195.68 1195.68 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 37.92 37.92 united health care ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 37.92 37.92 united health care pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 37.92 37.92 united health care hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 37.92 37.92 united health care epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 37.92 37.92 united health care hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2285.63 2285.63 united health care ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2285.63 2285.63 united health care pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2285.63 2285.63 united health care hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2285.63 2285.63 united health care epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 2285.63 2285.63 united health care hmo postoperative and post-traumatic infections without mcc ms-drg 863 15967.49 15967.49 2487.74 2487.74 15221.04 15221.04 12684.2 12684.2 I 15967.49 15967.49 united health care ppo postoperative and post-traumatic infections without mcc ms-drg 863 15967.49 15967.49 2487.74 2487.74 15221.04 15221.04 12684.2 12684.2 I 15967.49 15967.49 united health care pos postoperative and post-traumatic infections without mcc ms-drg 863 15967.49 15967.49 2487.74 2487.74 15221.04 15221.04 12684.2 12684.2 I 15967.49 15967.49 united health care hmo postoperative and post-traumatic infections without mcc ms-drg 863 15967.49 15967.49 2487.74 2487.74 15221.04 15221.04 12684.2 12684.2 I 15967.49 15967.49 united health care epo postoperative and post-traumatic infections without mcc ms-drg 863 15967.49 15967.49 2487.74 2487.74 15221.04 15221.04 12684.2 12684.2 I 15967.49 15967.49 united health care hmo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 50.5 50.5 united health care ppo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 50.5 50.5 united health care pos "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 50.5 50.5 united health care hmo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 50.5 50.5 united health care epo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 50.5 50.5 united health care hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care pos "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care epo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care hmo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1986.81 1986.81 united health care ppo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1986.81 1986.81 united health care pos MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1986.81 1986.81 united health care hmo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1986.81 1986.81 united health care epo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1986.81 1986.81 united health care hmo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 898.85 898.85 united health care ppo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 898.85 898.85 united health care pos CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 898.85 898.85 united health care hmo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 898.85 898.85 united health care epo CT scan pelvis with contrast cpt 72193 898.85 898.85 158.85 158.85 1507.32 1507.32 1256.1 1256.1 O 898.85 898.85 united health care hmo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 75.05 75.05 united health care ppo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 75.05 75.05 united health care pos Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 75.05 75.05 united health care hmo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 75.05 75.05 united health care epo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 75.05 75.05 united health care hmo CT scan pelvis with contrast cpt 72193 989.18 989.18 161.43 161.43 1507.32 1507.32 1256.1 1256.1 E 989.18 989.18 united health care ppo CT scan pelvis with contrast cpt 72193 989.18 989.18 161.43 161.43 1507.32 1507.32 1256.1 1256.1 E 989.18 989.18 united health care pos CT scan pelvis with contrast cpt 72193 989.18 989.18 161.43 161.43 1507.32 1507.32 1256.1 1256.1 E 989.18 989.18 united health care hmo CT scan pelvis with contrast cpt 72193 989.18 989.18 161.43 161.43 1507.32 1507.32 1256.1 1256.1 E 989.18 989.18 united health care epo CT scan pelvis with contrast cpt 72193 989.18 989.18 161.43 161.43 1507.32 1507.32 1256.1 1256.1 E 989.18 989.18 united health care hmo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1933.28 1933.28 united health care ppo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1933.28 1933.28 united health care pos MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1933.28 1933.28 united health care hmo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1933.28 1933.28 united health care epo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1933.28 1933.28 united health care hmo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 34.58 34.58 united health care ppo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 34.58 34.58 united health care pos "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 34.58 34.58 united health care hmo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 34.58 34.58 united health care epo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 34.58 34.58 united health care hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 841.91 841.91 united health care ppo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 841.91 841.91 united health care pos ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 841.91 841.91 united health care hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 841.91 841.91 united health care epo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 841.91 841.91 united health care hmo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 31.85 31.85 united health care ppo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 31.85 31.85 united health care pos Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 31.85 31.85 united health care hmo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 31.85 31.85 united health care epo Antibody identification test for white blood cell antibodies cpt 86021 31.85 31.85 13.39 13.39 172.28 172.28 143.57 143.57 O 31.85 31.85 united health care hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care ppo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care pos MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care hmo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care epo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1942.19 1942.19 united health care hmo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 1688.63 1688.63 united health care ppo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 1688.63 1688.63 united health care pos MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 1688.63 1688.63 united health care hmo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 1688.63 1688.63 united health care epo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 1688.63 1688.63 united health care hmo bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 841.91 841.91 united health care ppo bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 841.91 841.91 united health care pos bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 841.91 841.91 united health care hmo bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 841.91 841.91 united health care epo bls-emergency cpt A0429 841.91 841.91 304.23 304.23 1293.62 1293.62 1078.02 1078.02 O 841.91 841.91 united health care hmo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care ppo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care pos MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care hmo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care epo MRI scan of middle spinal canal before and after contrast cpt 72157 2577.39 2577.39 219.52 219.52 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care hmo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 33.41 33.41 united health care ppo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 33.41 33.41 united health care pos "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 33.41 33.41 united health care hmo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 33.41 33.41 united health care epo "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" cpt 82952 33.41 33.41 3.49 3.49 52.15 52.15 43.46 43.46 O 33.41 33.41 united health care hmo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 423.74 423.74 united health care ppo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 423.74 423.74 united health care pos "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 423.74 423.74 united health care hmo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 423.74 423.74 united health care epo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 423.74 423.74 united health care hmo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 23.85 23.85 united health care ppo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 23.85 23.85 united health care pos "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 23.85 23.85 united health care hmo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 23.85 23.85 united health care epo "Coagulation assessment blood test, substitution, plasma fractions" cpt 85732 23.85 23.85 4.28 4.28 38.16 38.16 31.8 31.8 O 23.85 23.85 united health care hmo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1833.84 1833.84 united health care ppo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1833.84 1833.84 united health care pos Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1833.84 1833.84 united health care hmo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1833.84 1833.84 united health care epo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1833.84 1833.84 united health care hmo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care ppo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care pos MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care hmo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care epo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 2577.39 2577.39 united health care hmo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 252.09 252.09 united health care ppo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 252.09 252.09 united health care pos "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 252.09 252.09 united health care hmo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 252.09 252.09 united health care epo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 252.09 252.09 23.05 23.05 384.14 384.14 320.12 320.12 E 252.09 252.09 united health care hmo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 59746.02 59746.02 united health care ppo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 59746.02 59746.02 united health care pos major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 59746.02 59746.02 united health care hmo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 59746.02 59746.02 united health care epo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 59746.02 59746.02 united health care hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 232.14 232.14 united health care ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 232.14 232.14 united health care pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 232.14 232.14 united health care hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 232.14 232.14 united health care epo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 232.14 232.14 united health care hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 1642.08 1642.08 united health care ppo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 1642.08 1642.08 united health care pos CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 1642.08 1642.08 united health care hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 1642.08 1642.08 united health care epo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 1642.08 1642.08 united health care hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1652.81 1652.81 united health care ppo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1652.81 1652.81 united health care pos CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1652.81 1652.81 united health care hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1652.81 1652.81 united health care epo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 1652.81 1652.81 united health care hmo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 10082.72 10082.72 united health care ppo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 10082.72 10082.72 united health care pos tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 10082.72 10082.72 united health care hmo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 10082.72 10082.72 united health care epo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 10082.72 10082.72 united health care hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 5421.31 5421.31 united health care ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 5421.31 5421.31 united health care pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 5421.31 5421.31 united health care hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 5421.31 5421.31 united health care epo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 5421.31 5421.31 united health care hmo "X-ray of pelvis, 1 or 2 views" cpt 72170 152.64 152.64 20.47 20.47 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care ppo "X-ray of pelvis, 1 or 2 views" cpt 72170 152.64 152.64 20.47 20.47 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care pos "X-ray of pelvis, 1 or 2 views" cpt 72170 152.64 152.64 20.47 20.47 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care hmo "X-ray of pelvis, 1 or 2 views" cpt 72170 152.64 152.64 20.47 20.47 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care epo "X-ray of pelvis, 1 or 2 views" cpt 72170 152.64 152.64 20.47 20.47 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 35.04 35.04 united health care ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 35.04 35.04 united health care pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 35.04 35.04 united health care hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 35.04 35.04 united health care epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 35.04 35.04 united health care hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care pos "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care epo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care hmo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 2710.24 2710.24 united health care ppo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 2710.24 2710.24 united health care pos tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 2710.24 2710.24 united health care hmo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 2710.24 2710.24 united health care epo tc99m medronate cpt A9503 2710.24 2710.24 376.66 376.66 5915.28 5915.28 4929.4 4929.4 O 2710.24 2710.24 united health care hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 127330.68 127330.68 united health care ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 127330.68 127330.68 united health care pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 127330.68 127330.68 united health care hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 127330.68 127330.68 united health care epo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 127330.68 127330.68 united health care hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 92.1 92.1 united health care ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 92.1 92.1 united health care pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 92.1 92.1 united health care hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 92.1 92.1 united health care epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 92.1 92.1 united health care hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 345.82 345.82 united health care ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 345.82 345.82 united health care pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 345.82 345.82 united health care hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 345.82 345.82 united health care epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 345.82 345.82 united health care hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 2994.51 2994.51 united health care ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 2994.51 2994.51 united health care pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 2994.51 2994.51 united health care hmo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 2994.51 2994.51 united health care epo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 2994.51 2994.51 united health care hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 232.14 232.14 united health care ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 232.14 232.14 united health care pos "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 232.14 232.14 united health care hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 232.14 232.14 united health care epo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 232.14 232.14 united health care hmo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 38438.58 38438.58 united health care ppo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 38438.58 38438.58 united health care pos peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 38438.58 38438.58 united health care hmo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 38438.58 38438.58 united health care epo peritoneal adhesiolysis without cc/mcc ms-drg 337 38438.58 38438.58 7551.91 7551.91 64945.27 64945.27 54121.06 54121.06 I 38438.58 38438.58 united health care hmo "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care ppo "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care pos "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care hmo "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care epo "X-ray of pelvis, minimum of 2 views" cpt 72220 152.64 152.64 18.36 18.36 244.22 244.22 203.52 203.52 E 152.64 152.64 united health care hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care epo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 17.46 17.46 272.21 272.21 226.84 226.84 E 178.64 178.64 united health care hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 178.64 178.64 united health care ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 178.64 178.64 united health care pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 178.64 178.64 united health care hmo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 178.64 178.64 united health care epo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 178.64 178.64 united health care hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 2189.43 2189.43 united health care ppo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 2189.43 2189.43 united health care pos "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 2189.43 2189.43 united health care hmo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 2189.43 2189.43 united health care epo "Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level" cpt 64483 2189.43 2189.43 657.1 657.1 2335.45 2335.45 1946.21 1946.21 O 2189.43 2189.43 united health care hmo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 30.21 30.21 united health care ppo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 30.21 30.21 united health care pos "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 30.21 30.21 united health care hmo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 30.21 30.21 united health care epo "Clotting factor X assessment test, diluted" cpt 85613 30.21 30.21 5.42 5.42 48.34 48.34 40.28 40.28 O 30.21 30.21 united health care hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 6259.46 6259.46 united health care ppo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 6259.46 6259.46 united health care pos f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 6259.46 6259.46 united health care hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 6259.46 6259.46 united health care epo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 6259.46 6259.46 united health care hmo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1477.69 1477.69 united health care ppo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1477.69 1477.69 united health care pos Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1477.69 1477.69 united health care hmo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1477.69 1477.69 united health care epo Injection of substance into spinal canal of lower back or sacrum using imaging guidance cpt 62323 1477.69 1477.69 165.81 165.81 2354.11 2354.11 1961.76 1961.76 O 1477.69 1477.69 united health care hmo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 60.42 60.42 united health care ppo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 60.42 60.42 united health care pos Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 60.42 60.42 united health care hmo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 60.42 60.42 united health care epo Platelet function test cpt 85597 60.42 60.42 10.84 10.84 96.67 96.67 80.56 80.56 O 60.42 60.42 united health care hmo Injection of substance into spinal canal of lower back or sacrum cpt 62322 1477.69 1477.69 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 1477.69 1477.69 united health care ppo Injection of substance into spinal canal of lower back or sacrum cpt 62322 1477.69 1477.69 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 1477.69 1477.69 united health care pos Injection of substance into spinal canal of lower back or sacrum cpt 62322 1477.69 1477.69 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 1477.69 1477.69 united health care hmo Injection of substance into spinal canal of lower back or sacrum cpt 62322 1477.69 1477.69 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 1477.69 1477.69 united health care epo Injection of substance into spinal canal of lower back or sacrum cpt 62322 1477.69 1477.69 505.78 505.78 1667.24 1667.24 1389.37 1389.37 O 1477.69 1477.69 united health care hmo Fibrinogen (factor 1) activity measurement cpt 85384 51 51 8.65 8.65 102.52 102.52 85.43 85.43 O 51 51 united health care ppo Fibrinogen (factor 1) activity measurement cpt 85384 51 51 8.65 8.65 102.52 102.52 85.43 85.43 O 51 51 united health care pos Fibrinogen (factor 1) activity measurement cpt 85384 51 51 8.65 8.65 102.52 102.52 85.43 85.43 O 51 51 united health care hmo Fibrinogen (factor 1) activity measurement cpt 85384 51 51 8.65 8.65 102.52 102.52 85.43 85.43 O 51 51 united health care epo Fibrinogen (factor 1) activity measurement cpt 85384 51 51 8.65 8.65 102.52 102.52 85.43 85.43 O 51 51 united health care hmo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 2833.93 2833.93 united health care ppo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 2833.93 2833.93 united health care pos "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 2833.93 2833.93 united health care hmo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 2833.93 2833.93 united health care epo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 2833.93 2833.93 united health care hmo Fibrinogen (factor 1) activity measurement cpt 85384 64.07 64.07 64.07 64.07 102.52 102.52 85.43 85.43 E 64.07 64.07 united health care ppo Fibrinogen (factor 1) activity measurement cpt 85384 64.07 64.07 64.07 64.07 102.52 102.52 85.43 85.43 E 64.07 64.07 united health care pos Fibrinogen (factor 1) activity measurement cpt 85384 64.07 64.07 64.07 64.07 102.52 102.52 85.43 85.43 E 64.07 64.07 united health care hmo Fibrinogen (factor 1) activity measurement cpt 85384 64.07 64.07 64.07 64.07 102.52 102.52 85.43 85.43 E 64.07 64.07 united health care epo Fibrinogen (factor 1) activity measurement cpt 85384 64.07 64.07 64.07 64.07 102.52 102.52 85.43 85.43 E 64.07 64.07 united health care hmo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 7803.63 7803.63 united health care ppo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 7803.63 7803.63 united health care pos Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 7803.63 7803.63 united health care hmo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 7803.63 7803.63 united health care epo Biopsy of prostate gland cpt 55700 8816.24 8816.24 1569.38 1569.38 15572.48 15572.48 12977.07 12977.07 O 7803.63 7803.63 united health care hmo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 155.65 155.65 united health care ppo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 155.65 155.65 united health care pos "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 155.65 155.65 united health care hmo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 155.65 155.65 united health care epo "X-ray of chest, 1 view" cpt 71045 155.65 155.65 13.25 13.25 242.95 242.95 202.46 202.46 O 155.65 155.65 united health care hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 26638.49 26638.49 united health care ppo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 26638.49 26638.49 united health care pos "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 26638.49 26638.49 united health care hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 26638.49 26638.49 united health care epo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 26638.49 26638.49 united health care hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 82.6 82.6 united health care ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 82.6 82.6 united health care pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 82.6 82.6 united health care hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 82.6 82.6 united health care epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 82.6 82.6 united health care hmo "brachytx, non-str,hdr ir-192" cpt C1717 16700.63 16700.63 5450.85 5450.85 24193.44 24193.44 20161.2 20161.2 O 16700.63 16700.63 united health care ppo "brachytx, non-str,hdr ir-192" cpt C1717 16700.63 16700.63 5450.85 5450.85 24193.44 24193.44 20161.2 20161.2 O 16700.63 16700.63 united health care pos "brachytx, non-str,hdr ir-192" cpt C1717 16700.63 16700.63 5450.85 5450.85 24193.44 24193.44 20161.2 20161.2 O 16700.63 16700.63 united health care hmo "brachytx, non-str,hdr ir-192" cpt C1717 16700.63 16700.63 5450.85 5450.85 24193.44 24193.44 20161.2 20161.2 O 16700.63 16700.63 united health care epo "brachytx, non-str,hdr ir-192" cpt C1717 16700.63 16700.63 5450.85 5450.85 24193.44 24193.44 20161.2 20161.2 O 16700.63 16700.63 united health care hmo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 17009.14 17009.14 united health care ppo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 17009.14 17009.14 united health care pos Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 17009.14 17009.14 united health care hmo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 17009.14 17009.14 united health care epo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 17009.14 17009.14 united health care hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 82.6 82.6 united health care ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 82.6 82.6 united health care pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 82.6 82.6 united health care hmo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 82.6 82.6 united health care epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 82.6 82.6 united health care hmo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 10996.19 10996.19 united health care ppo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 10996.19 10996.19 united health care pos "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 10996.19 10996.19 united health care hmo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 10996.19 10996.19 united health care epo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 10996.19 10996.19 united health care hmo Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 6865.24 6865.24 united health care ppo Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 6865.24 6865.24 united health care pos Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 6865.24 6865.24 united health care hmo Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 6865.24 6865.24 united health care epo Critical care delivery critically ill or injured patient cpt 99292 14238.66 14238.66 1117.84 1117.84 12017.2 12017.2 10014.33 10014.33 O 6865.24 6865.24 united health care hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 151.85 151.85 united health care ppo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 151.85 151.85 united health care pos "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 151.85 151.85 united health care hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 151.85 151.85 united health care epo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 151.85 151.85 united health care hmo "X-ray of upper arm, minimum of 2 views" cpt 73060 22.61 22.61 19.15 19.15 249.31 249.31 207.76 207.76 E 22.61 22.61 united health care ppo "X-ray of upper arm, minimum of 2 views" cpt 73060 22.61 22.61 19.15 19.15 249.31 249.31 207.76 207.76 E 22.61 22.61 united health care pos "X-ray of upper arm, minimum of 2 views" cpt 73060 22.61 22.61 19.15 19.15 249.31 249.31 207.76 207.76 E 22.61 22.61 united health care hmo "X-ray of upper arm, minimum of 2 views" cpt 73060 22.61 22.61 19.15 19.15 249.31 249.31 207.76 207.76 E 22.61 22.61 united health care epo "X-ray of upper arm, minimum of 2 views" cpt 73060 22.61 22.61 19.15 19.15 249.31 249.31 207.76 207.76 E 22.61 22.61 united health care hmo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 20.28 20.28 united health care ppo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 20.28 20.28 united health care pos Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 20.28 20.28 united health care hmo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 20.28 20.28 united health care epo Urine volume measurement cpt 81050 20.28 20.28 3.24 3.24 32.44 32.44 27.03 27.03 O 20.28 20.28 united health care hmo "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 59.86 59.86 united health care ppo "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 59.86 59.86 united health care pos "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 59.86 59.86 united health care hmo "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 59.86 59.86 united health care epo "Ketone bodies analysis, quantitative" cpt 82010 59.86 59.86 7.27 7.27 95.77 95.77 79.81 79.81 E 59.86 59.86 united health care hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 5325.99 5325.99 united health care ppo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 5325.99 5325.99 united health care pos "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 5325.99 5325.99 united health care hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 5325.99 5325.99 united health care epo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 5325.99 5325.99 united health care hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 17035.81 17035.81 united health care ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 17035.81 17035.81 united health care pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 17035.81 17035.81 united health care hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 17035.81 17035.81 united health care epo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 17035.81 17035.81 united health care hmo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care ppo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care pos "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care hmo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care epo "Platelet count, automated test" cpt 85049 25.7 25.7 3.98 3.98 39.17 39.17 32.64 32.64 O 25.7 25.7 united health care hmo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care ppo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care pos MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care hmo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care epo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care hmo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care ppo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care pos "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care hmo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care epo "Red blood count, automated test" cpt 85045 26.24 26.24 3.55 3.55 41.98 41.98 34.98 34.98 O 26.24 26.24 united health care hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 3009.12 3009.12 united health care ppo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 3009.12 3009.12 united health care pos "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 3009.12 3009.12 united health care hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 3009.12 3009.12 united health care epo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 3009.12 3009.12 united health care hmo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 28.84 28.84 united health care ppo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 28.84 28.84 united health care pos "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 28.84 28.84 united health care hmo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 28.84 28.84 united health care epo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 28.84 28.84 united health care hmo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 2356.82 2356.82 united health care ppo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 2356.82 2356.82 united health care pos "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 2356.82 2356.82 united health care hmo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 2356.82 2356.82 united health care epo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 2356.82 2356.82 united health care hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3567.22 3567.22 united health care ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3567.22 3567.22 united health care pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3567.22 3567.22 united health care hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3567.22 3567.22 united health care epo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 3567.22 3567.22 united health care hmo guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 23096.99 23096.99 united health care ppo guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 23096.99 23096.99 united health care pos guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 23096.99 23096.99 united health care hmo guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 23096.99 23096.99 united health care epo guide wire cpt C1769 23096.99 23096.99 1592.33 1592.33 47378.09 47378.09 39481.74 39481.74 E 23096.99 23096.99 united health care hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 16039.46 16039.46 united health care ppo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 16039.46 16039.46 united health care pos guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 16039.46 16039.46 united health care hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 16039.46 16039.46 united health care epo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 16039.46 16039.46 united health care hmo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 13.52 13.52 united health care ppo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 13.52 13.52 united health care pos "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 13.52 13.52 united health care hmo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 13.52 13.52 united health care epo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 13.52 13.52 united health care hmo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6117.97 6117.97 united health care ppo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6117.97 6117.97 united health care pos gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6117.97 6117.97 united health care hmo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6117.97 6117.97 united health care epo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 6117.97 6117.97 united health care hmo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 541.4 541.4 united health care ppo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 541.4 541.4 united health care pos "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 541.4 541.4 united health care hmo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 541.4 541.4 united health care epo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 541.4 541.4 united health care hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 793.25 793.25 united health care ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 793.25 793.25 united health care pos "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 793.25 793.25 united health care hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 793.25 793.25 united health care epo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 793.25 793.25 united health care hmo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care ppo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care pos "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care hmo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care epo "Hydroxyprogesterone, 17-D (synthetic hormone) level" cpt 83498 85.07 85.07 16.24 16.24 136.1 136.1 113.42 113.42 O 85.07 85.07 united health care hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care pos Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care hmo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care epo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 28.7 28.7 united health care hmo Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 149.46 149.46 united health care ppo Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 149.46 149.46 united health care pos Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 149.46 149.46 united health care hmo Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 149.46 149.46 united health care epo Adrenocorticotropic hormone (ACTH) level cpt 82024 149.46 149.46 34.35 34.35 239.14 239.14 199.28 199.28 O 149.46 149.46 united health care hmo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 31.01 31.01 united health care ppo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 31.01 31.01 united health care pos "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 31.01 31.01 united health care hmo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 31.01 31.01 united health care epo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 31.01 31.01 united health care hmo "X-ray of forearm, 2 views" cpt 73090 163.61 163.61 16.56 16.56 249.31 249.31 207.76 207.76 E 163.61 163.61 united health care ppo "X-ray of forearm, 2 views" cpt 73090 163.61 163.61 16.56 16.56 249.31 249.31 207.76 207.76 E 163.61 163.61 united health care pos "X-ray of forearm, 2 views" cpt 73090 163.61 163.61 16.56 16.56 249.31 249.31 207.76 207.76 E 163.61 163.61 united health care hmo "X-ray of forearm, 2 views" cpt 73090 163.61 163.61 16.56 16.56 249.31 249.31 207.76 207.76 E 163.61 163.61 united health care epo "X-ray of forearm, 2 views" cpt 73090 163.61 163.61 16.56 16.56 249.31 249.31 207.76 207.76 E 163.61 163.61 united health care hmo "Blood count, hemoglobin" cpt 85018 25.22 25.22 2.11 2.11 49.61 49.61 41.34 41.34 E 25.22 25.22 united health care ppo "Blood count, hemoglobin" cpt 85018 25.22 25.22 2.11 2.11 49.61 49.61 41.34 41.34 E 25.22 25.22 united health care pos "Blood count, hemoglobin" cpt 85018 25.22 25.22 2.11 2.11 49.61 49.61 41.34 41.34 E 25.22 25.22 united health care hmo "Blood count, hemoglobin" cpt 85018 25.22 25.22 2.11 2.11 49.61 49.61 41.34 41.34 E 25.22 25.22 united health care epo "Blood count, hemoglobin" cpt 85018 25.22 25.22 2.11 2.11 49.61 49.61 41.34 41.34 E 25.22 25.22 united health care hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care epo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 49.76 49.76 united health care hmo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 16489.31 16489.31 united health care ppo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 16489.31 16489.31 united health care pos gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 16489.31 16489.31 united health care hmo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 16489.31 16489.31 united health care epo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 16489.31 16489.31 united health care hmo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 195.33 195.33 united health care ppo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 195.33 195.33 united health care pos "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 195.33 195.33 united health care hmo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 195.33 195.33 united health care epo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 195.33 195.33 united health care hmo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 30.21 30.21 united health care ppo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 30.21 30.21 united health care pos Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 30.21 30.21 united health care hmo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 30.21 30.21 united health care epo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 30.21 30.21 united health care hmo "Emergency department visit, self limited or minor problem" cpt 99281 137.73 137.73 56.33 56.33 209.88 209.88 174.9 174.9 E 137.73 137.73 united health care ppo "Emergency department visit, self limited or minor problem" cpt 99281 137.73 137.73 56.33 56.33 209.88 209.88 174.9 174.9 E 137.73 137.73 united health care pos "Emergency department visit, self limited or minor problem" cpt 99281 137.73 137.73 56.33 56.33 209.88 209.88 174.9 174.9 E 137.73 137.73 united health care hmo "Emergency department visit, self limited or minor problem" cpt 99281 137.73 137.73 56.33 56.33 209.88 209.88 174.9 174.9 E 137.73 137.73 united health care epo "Emergency department visit, self limited or minor problem" cpt 99281 137.73 137.73 56.33 56.33 209.88 209.88 174.9 174.9 E 137.73 137.73 united health care hmo "Established patient office or other outpatient, visit typically 40 minutes" cpt 99215 467.02 467.02 178.52 178.52 3877.06 3877.06 3230.88 3230.88 O 467.02 467.02 united health care ppo "Established patient office or other outpatient, visit typically 40 minutes" cpt 99215 467.02 467.02 178.52 178.52 3877.06 3877.06 3230.88 3230.88 O 467.02 467.02 united health care pos "Established patient office or other outpatient, visit typically 40 minutes" cpt 99215 467.02 467.02 178.52 178.52 3877.06 3877.06 3230.88 3230.88 O 467.02 467.02 united health care hmo "Established patient office or other outpatient, visit typically 40 minutes" cpt 99215 467.02 467.02 178.52 178.52 3877.06 3877.06 3230.88 3230.88 O 467.02 467.02 united health care epo "Established patient office or other outpatient, visit typically 40 minutes" cpt 99215 467.02 467.02 178.52 178.52 3877.06 3877.06 3230.88 3230.88 O 467.02 467.02 united health care hmo Red blood cell concentration measurement cpt 85014 22.63 22.63 2.11 2.11 44.52 44.52 37.1 37.1 E 22.63 22.63 united health care ppo Red blood cell concentration measurement cpt 85014 22.63 22.63 2.11 2.11 44.52 44.52 37.1 37.1 E 22.63 22.63 united health care pos Red blood cell concentration measurement cpt 85014 22.63 22.63 2.11 2.11 44.52 44.52 37.1 37.1 E 22.63 22.63 united health care hmo Red blood cell concentration measurement cpt 85014 22.63 22.63 2.11 2.11 44.52 44.52 37.1 37.1 E 22.63 22.63 united health care epo Red blood cell concentration measurement cpt 85014 22.63 22.63 2.11 2.11 44.52 44.52 37.1 37.1 E 22.63 22.63 united health care hmo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 1656.52 1656.52 united health care ppo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 1656.52 1656.52 united health care pos "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 1656.52 1656.52 united health care hmo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 1656.52 1656.52 united health care epo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 1656.52 1656.52 united health care hmo "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 23096.99 23096.99 united health care ppo "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 23096.99 23096.99 united health care pos "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 23096.99 23096.99 united health care hmo "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 23096.99 23096.99 united health care epo "catheter, guiding" cpt C1887 23096.99 23096.99 1429.11 1429.11 64540.26 64540.26 53783.55 53783.55 E 23096.99 23096.99 united health care hmo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 232.89 232.89 united health care ppo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 232.89 232.89 united health care pos "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 232.89 232.89 united health care hmo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 232.89 232.89 united health care epo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 232.89 232.89 united health care hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 78.71 78.71 united health care ppo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 78.71 78.71 united health care pos Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 78.71 78.71 united health care hmo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 78.71 78.71 united health care epo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 78.71 78.71 united health care hmo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 14578.4 14578.4 united health care ppo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 14578.4 14578.4 united health care pos "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 14578.4 14578.4 united health care hmo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 14578.4 14578.4 united health care epo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 14578.4 14578.4 united health care hmo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 194.95 194.95 united health care ppo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 194.95 194.95 united health care pos "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 194.95 194.95 united health care hmo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 194.95 194.95 united health care epo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 194.95 194.95 united health care hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 51.68 51.68 united health care ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 51.68 51.68 united health care pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 51.68 51.68 united health care hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 51.68 51.68 united health care epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 51.68 51.68 united health care hmo "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 23096.99 23096.99 united health care ppo "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 23096.99 23096.99 united health care pos "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 23096.99 23096.99 united health care hmo "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 23096.99 23096.99 united health care epo "intro/sheath, non-laser" cpt C1894 23096.99 23096.99 1723.62 1723.62 54105.9 54105.9 45088.25 45088.25 E 23096.99 23096.99 united health care hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 16160.85 16160.85 united health care ppo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 16160.85 16160.85 united health care pos "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 16160.85 16160.85 united health care hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 16160.85 16160.85 united health care epo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 16160.85 16160.85 united health care hmo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 827.97 827.97 united health care ppo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 827.97 827.97 united health care pos "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 827.97 827.97 united health care hmo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 827.97 827.97 united health care epo "Established patient office or other outpatient visit, typically 10 minutes" cpt 99212 827.97 827.97 65.61 65.61 1122.79 1122.79 935.66 935.66 O 827.97 827.97 united health care hmo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 12072.4 12072.4 united health care ppo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 12072.4 12072.4 united health care pos Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 12072.4 12072.4 united health care hmo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 12072.4 12072.4 united health care epo Partial removal of breast cpt 19301 12072.4 12072.4 221.33 221.33 22422.11 22422.11 18685.09 18685.09 O 12072.4 12072.4 united health care hmo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 96.49 96.49 united health care ppo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 96.49 96.49 united health care pos Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 96.49 96.49 united health care hmo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 96.49 96.49 united health care epo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 96.49 96.49 united health care hmo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 235.82 235.82 united health care ppo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 235.82 235.82 united health care pos "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 235.82 235.82 united health care hmo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 235.82 235.82 united health care epo "Established patient office or other outpatient visit, typically 5 minutes" cpt 99211 259.15 259.15 51.31 51.31 427.9 427.9 356.58 356.58 O 235.82 235.82 united health care hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 16039.46 16039.46 united health care ppo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 16039.46 16039.46 united health care pos "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 16039.46 16039.46 united health care hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 16039.46 16039.46 united health care epo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 16039.46 16039.46 united health care hmo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care ppo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care pos "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care hmo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care epo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 221.81 221.81 united health care hmo "X-ray of skull, complete, minimum of 4 views" cpt 70260 342.65 342.65 24.84 24.84 548.23 548.23 456.86 456.86 O 342.65 342.65 united health care ppo "X-ray of skull, complete, minimum of 4 views" cpt 70260 342.65 342.65 24.84 24.84 548.23 548.23 456.86 456.86 O 342.65 342.65 united health care pos "X-ray of skull, complete, minimum of 4 views" cpt 70260 342.65 342.65 24.84 24.84 548.23 548.23 456.86 456.86 O 342.65 342.65 united health care hmo "X-ray of skull, complete, minimum of 4 views" cpt 70260 342.65 342.65 24.84 24.84 548.23 548.23 456.86 456.86 O 342.65 342.65 united health care epo "X-ray of skull, complete, minimum of 4 views" cpt 70260 342.65 342.65 24.84 24.84 548.23 548.23 456.86 456.86 O 342.65 342.65 united health care hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 232.89 232.89 united health care ppo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 232.89 232.89 united health care pos "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 232.89 232.89 united health care hmo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 232.89 232.89 united health care epo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 232.89 232.89 united health care hmo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 2233.71 2233.71 united health care ppo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 2233.71 2233.71 united health care pos "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 2233.71 2233.71 united health care hmo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 2233.71 2233.71 united health care epo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 2233.71 2233.71 united health care hmo "X-ray of skull, less than 4 views" cpt 70250 186.03 186.03 21.31 21.31 297.65 297.65 248.04 248.04 E 186.03 186.03 united health care ppo "X-ray of skull, less than 4 views" cpt 70250 186.03 186.03 21.31 21.31 297.65 297.65 248.04 248.04 E 186.03 186.03 united health care pos "X-ray of skull, less than 4 views" cpt 70250 186.03 186.03 21.31 21.31 297.65 297.65 248.04 248.04 E 186.03 186.03 united health care hmo "X-ray of skull, less than 4 views" cpt 70250 186.03 186.03 21.31 21.31 297.65 297.65 248.04 248.04 E 186.03 186.03 united health care epo "X-ray of skull, less than 4 views" cpt 70250 186.03 186.03 21.31 21.31 297.65 297.65 248.04 248.04 E 186.03 186.03 united health care hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 45.32 45.32 united health care ppo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 45.32 45.32 united health care pos "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 45.32 45.32 united health care hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 45.32 45.32 united health care epo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 45.32 45.32 united health care hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 16039.46 16039.46 united health care ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 16039.46 16039.46 united health care pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 16039.46 16039.46 united health care hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 16039.46 16039.46 united health care epo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 16039.46 16039.46 united health care hmo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 19333.82 19333.82 united health care ppo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 19333.82 19333.82 united health care pos laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 19333.82 19333.82 united health care hmo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 19333.82 19333.82 united health care epo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 19333.82 19333.82 united health care hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 122.23 122.23 united health care ppo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 122.23 122.23 united health care pos "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 122.23 122.23 united health care hmo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 122.23 122.23 united health care epo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 122.23 122.23 united health care hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 23096.99 23096.99 united health care ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 23096.99 23096.99 united health care pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 23096.99 23096.99 united health care hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 23096.99 23096.99 united health care epo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 23096.99 23096.99 1592.33 1592.33 46025.03 46025.03 38354.19 38354.19 E 23096.99 23096.99 united health care hmo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 7574.88 7574.88 united health care ppo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 7574.88 7574.88 united health care pos cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 7574.88 7574.88 united health care hmo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 7574.88 7574.88 united health care epo cirrhosis and alcoholic hepatitis with cc ms-drg 433 10629.2 10629.2 5338.33 5338.33 25230.89 25230.89 21025.74 21025.74 I 7574.88 7574.88 united health care hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care epo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 47.82 47.82 united health care hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15942.66 15942.66 united health care ppo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15942.66 15942.66 united health care pos septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15942.66 15942.66 united health care hmo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15942.66 15942.66 united health care epo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 15942.66 15942.66 united health care hmo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 6390.02 6390.02 united health care ppo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 6390.02 6390.02 united health care pos admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 6390.02 6390.02 united health care hmo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 6390.02 6390.02 united health care epo admin influenza virus vac cpt G0008 14191.44 14191.44 325.88 325.88 451.68 451.68 376.4 376.4 O 6390.02 6390.02 united health care hmo Aldosterone hormone level cpt 82088 141.51 141.51 39.93 39.93 226.42 226.42 188.68 188.68 O 141.51 141.51 united health care ppo Aldosterone hormone level cpt 82088 141.51 141.51 39.93 39.93 226.42 226.42 188.68 188.68 O 141.51 141.51 united health care pos Aldosterone hormone level cpt 82088 141.51 141.51 39.93 39.93 226.42 226.42 188.68 188.68 O 141.51 141.51 united health care hmo Aldosterone hormone level cpt 82088 141.51 141.51 39.93 39.93 226.42 226.42 188.68 188.68 O 141.51 141.51 united health care epo Aldosterone hormone level cpt 82088 141.51 141.51 39.93 39.93 226.42 226.42 188.68 188.68 O 141.51 141.51 united health care hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 897.77 897.77 united health care ppo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 897.77 897.77 united health care pos "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 897.77 897.77 united health care hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 897.77 897.77 united health care epo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 897.77 897.77 united health care hmo "X-ray of fingers, minimum of 2 views" cpt 73140 160.27 160.27 23.94 23.94 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care ppo "X-ray of fingers, minimum of 2 views" cpt 73140 160.27 160.27 23.94 23.94 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care pos "X-ray of fingers, minimum of 2 views" cpt 73140 160.27 160.27 23.94 23.94 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care hmo "X-ray of fingers, minimum of 2 views" cpt 73140 160.27 160.27 23.94 23.94 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care epo "X-ray of fingers, minimum of 2 views" cpt 73140 160.27 160.27 23.94 23.94 244.22 244.22 203.52 203.52 E 160.27 160.27 united health care hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 424.12 424.12 united health care ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 424.12 424.12 united health care pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 424.12 424.12 united health care hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 424.12 424.12 united health care epo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 424.12 424.12 united health care hmo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 2295.35 2295.35 united health care ppo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 2295.35 2295.35 united health care pos colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 2295.35 2295.35 united health care hmo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 2295.35 2295.35 united health care epo colorectal scrn; hi risk ind cpt G0105 2295.35 2295.35 676.71 676.71 3566.56 3566.56 2972.13 2972.13 O 2295.35 2295.35 united health care hmo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 13320.63 13320.63 united health care ppo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 13320.63 13320.63 united health care pos disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 13320.63 13320.63 united health care hmo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 13320.63 13320.63 united health care epo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 13320.63 13320.63 united health care hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 3567.98 3567.98 united health care ppo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 3567.98 3567.98 united health care pos "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 3567.98 3567.98 united health care hmo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 3567.98 3567.98 united health care epo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 3567.98 3567.98 united health care hmo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 100.17 100.17 united health care ppo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 100.17 100.17 united health care pos "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 100.17 100.17 united health care hmo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 100.17 100.17 united health care epo "Alpha-fetoprotein (AFP) level, serum" cpt 82105 100.17 100.17 14.92 14.92 160.27 160.27 133.56 133.56 O 100.17 100.17 united health care hmo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 2133.45 2133.45 united health care ppo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 2133.45 2133.45 united health care pos colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 2133.45 2133.45 united health care hmo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 2133.45 2133.45 united health care epo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 2133.45 2133.45 united health care hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 1124.67 1124.67 united health care ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 1124.67 1124.67 united health care pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 1124.67 1124.67 united health care hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 1124.67 1124.67 united health care epo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 10624.85 10624.85 64.2 64.2 2173.44 2173.44 1811.2 1811.2 O 1124.67 1124.67 united health care hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 6677.69 6677.69 united health care ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 6677.69 6677.69 united health care pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 6677.69 6677.69 united health care hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 6677.69 6677.69 united health care epo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 6677.69 6677.69 united health care hmo disorders of pancreas except malignancy without cc/mcc ms-drg 440 13723.07 13723.07 3523.84 3523.84 16448.54 16448.54 13707.12 13707.12 I 13723.07 13723.07 united health care ppo disorders of pancreas except malignancy without cc/mcc ms-drg 440 13723.07 13723.07 3523.84 3523.84 16448.54 16448.54 13707.12 13707.12 I 13723.07 13723.07 united health care pos disorders of pancreas except malignancy without cc/mcc ms-drg 440 13723.07 13723.07 3523.84 3523.84 16448.54 16448.54 13707.12 13707.12 I 13723.07 13723.07 united health care hmo disorders of pancreas except malignancy without cc/mcc ms-drg 440 13723.07 13723.07 3523.84 3523.84 16448.54 16448.54 13707.12 13707.12 I 13723.07 13723.07 united health care epo disorders of pancreas except malignancy without cc/mcc ms-drg 440 13723.07 13723.07 3523.84 3523.84 16448.54 16448.54 13707.12 13707.12 I 13723.07 13723.07 united health care hmo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 477.01 477.01 united health care ppo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 477.01 477.01 united health care pos "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 477.01 477.01 united health care hmo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 477.01 477.01 united health care epo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 477.01 477.01 united health care hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 1581.58 1581.58 united health care ppo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 1581.58 1581.58 united health care pos "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 1581.58 1581.58 united health care hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 1581.58 1581.58 united health care epo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 3099.83 3099.83 107.4 107.4 1865.47 1865.47 1554.56 1554.56 O 1581.58 1581.58 united health care hmo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 356.16 356.16 united health care ppo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 356.16 356.16 united health care pos Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 356.16 356.16 united health care hmo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 356.16 356.16 united health care epo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 356.16 356.16 united health care hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 2239.34 2239.34 united health care ppo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 2239.34 2239.34 united health care pos "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 2239.34 2239.34 united health care hmo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 2239.34 2239.34 united health care epo "Evaluation of physical therapy, typically 20 minutes" cpt 97161 2239.34 2239.34 90.94 90.94 2042.4 2042.4 1702 1702 O 2239.34 2239.34 united health care hmo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 6232.06 6232.06 united health care ppo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 6232.06 6232.06 united health care pos "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 6232.06 6232.06 united health care hmo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 6232.06 6232.06 united health care epo "Biopsy of breast accessed through the skin with ultrasound guidance, first lesion" cpt 19083 6232.06 6232.06 1196.5 1196.5 8369.4 8369.4 6974.5 6974.5 O 6232.06 6232.06 united health care hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care pos MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care hmo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care epo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 2039.29 2039.29 united health care hmo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 518.7 518.7 united health care ppo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 518.7 518.7 united health care pos "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 518.7 518.7 united health care hmo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 518.7 518.7 united health care epo "Injections of lower or sacral spine facet joint using imaging guidance, third and any additional level(s)" cpt 64495 3530.58 3530.58 518.7 518.7 4884.82 4884.82 4070.68 4070.68 O 518.7 518.7 united health care hmo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 228.98 228.98 united health care ppo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 228.98 228.98 united health care pos ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 228.98 228.98 united health care hmo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 228.98 228.98 united health care epo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 228.98 228.98 united health care hmo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 518.7 518.7 united health care ppo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 518.7 518.7 united health care pos "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 518.7 518.7 united health care hmo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 518.7 518.7 united health care epo "Injections of lower or sacral spine facet joint using imaging guidance, second level" cpt 64494 3530.58 3530.58 518.7 518.7 4848.4 4848.4 4040.33 4040.33 O 518.7 518.7 united health care hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 6503.5 6503.5 united health care ppo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 6503.5 6503.5 united health care pos hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 6503.5 6503.5 united health care hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 6503.5 6503.5 united health care epo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 6503.5 6503.5 united health care hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 35.39 35.39 united health care ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 35.39 35.39 united health care pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 35.39 35.39 united health care hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 35.39 35.39 united health care epo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 35.39 35.39 united health care hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 2460.86 2460.86 united health care ppo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 2460.86 2460.86 united health care pos "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 2460.86 2460.86 united health care hmo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 2460.86 2460.86 united health care epo "Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes" cpt 97530 2460.86 2460.86 213.15 213.15 4459.52 4459.52 3716.27 3716.27 O 2460.86 2460.86 united health care hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 34.19 34.19 united health care ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 34.19 34.19 united health care pos Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 34.19 34.19 united health care hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 34.19 34.19 united health care epo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 34.19 34.19 united health care hmo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 6491.02 6491.02 united health care ppo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 6491.02 6491.02 united health care pos "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 6491.02 6491.02 united health care hmo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 6491.02 6491.02 united health care epo "Manual (physical) therapy techniques to 1 or more regions, each 15 minutes" cpt 97140 6491.02 6491.02 634.07 634.07 5543.27 5543.27 4619.39 4619.39 O 6491.02 6491.02 united health care hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6390.02 6390.02 united health care ppo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6390.02 6390.02 united health care pos hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6390.02 6390.02 united health care hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6390.02 6390.02 united health care epo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 6390.02 6390.02 united health care hmo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 2498.67 2498.67 united health care ppo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 2498.67 2498.67 united health care pos "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 2498.67 2498.67 united health care hmo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 2498.67 2498.67 united health care epo "Therapeutic massage to 1 or more areas, each 15 minutes" cpt 97124 2498.67 2498.67 249.22 249.22 4774.56 4774.56 3978.8 3978.8 O 2498.67 2498.67 united health care hmo "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 147.5 147.5 united health care ppo "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 147.5 147.5 united health care pos "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 147.5 147.5 united health care hmo "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 147.5 147.5 united health care epo "X-ray of hip with pelvis, 2-3 views" cpt 73502 147.5 147.5 26.78 26.78 230.23 230.23 191.86 191.86 E 147.5 147.5 united health care hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4881.58 4881.58 united health care medicare advantage hmo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4881.58 4881.58 united health care medicare advantage ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4881.58 4881.58 united health care medicare advantage pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4881.58 4881.58 united health care medicare advantage epo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4881.58 4881.58 united health care medicare advantage ppo Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4881.58 4881.58 united health care medicare advantage pos Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour cpt 96367 5454.5 5454.5 1366.77 1366.77 16410.96 16410.96 13675.8 13675.8 O 4881.58 4881.58 united health care medicare advantage hmo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.52 1965.52 united health care medicare advantage hmo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.52 1965.52 united health care medicare advantage ppo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.52 1965.52 united health care medicare advantage pos regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.52 1965.52 united health care medicare advantage epo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.52 1965.52 united health care medicare advantage ppo regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.52 1965.52 united health care medicare advantage pos regadenoson injection cpt J2785 10082.72 10082.72 1489.46 1489.46 18139.98 18139.98 15116.65 15116.65 E 1965.52 1965.52 united health care medicare advantage hmo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4881.58 4881.58 united health care medicare advantage hmo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4881.58 4881.58 united health care medicare advantage ppo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4881.58 4881.58 united health care medicare advantage pos "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4881.58 4881.58 united health care medicare advantage epo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4881.58 4881.58 united health care medicare advantage ppo "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4881.58 4881.58 united health care medicare advantage pos "injection, udenyca 0.5 mg" cpt Q5111 8950.42 8950.42 4309.68 4309.68 42825.26 42825.26 35687.72 35687.72 O 4881.58 4881.58 united health care medicare advantage hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1952.13 1952.13 united health care medicare advantage hmo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1952.13 1952.13 united health care medicare advantage ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1952.13 1952.13 united health care medicare advantage pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1952.13 1952.13 united health care medicare advantage epo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1952.13 1952.13 united health care medicare advantage ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1952.13 1952.13 united health care medicare advantage pos Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 1952.13 1952.13 united health care medicare advantage hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 united health care medicare advantage hmo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 united health care medicare advantage ppo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 united health care medicare advantage pos Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 united health care medicare advantage epo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 united health care medicare advantage ppo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 united health care medicare advantage pos Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 889.62 889.62 united health care medicare advantage hmo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 418.12 418.12 united health care medicare advantage hmo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 418.12 418.12 united health care medicare advantage ppo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 418.12 418.12 united health care medicare advantage pos tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 418.12 418.12 united health care medicare advantage epo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 418.12 418.12 united health care medicare advantage ppo tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 418.12 418.12 united health care medicare advantage pos tc99m mebrofenin cpt A9537 1195.84 1195.84 348.86 348.86 1897.82 1897.82 1581.52 1581.52 O 418.12 418.12 united health care medicare advantage hmo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 united health care medicare advantage hmo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 united health care medicare advantage ppo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 united health care medicare advantage pos Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 united health care medicare advantage epo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 united health care medicare advantage ppo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 united health care medicare advantage pos Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 296.91 296.91 united health care medicare advantage hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 united health care medicare advantage hmo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 united health care medicare advantage ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 united health care medicare advantage pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 united health care medicare advantage epo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 united health care medicare advantage ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 united health care medicare advantage pos Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 22.38 22.38 united health care medicare advantage hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 united health care medicare advantage hmo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 united health care medicare advantage ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 united health care medicare advantage pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 united health care medicare advantage epo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 united health care medicare advantage ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 united health care medicare advantage pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 15.08 15.08 united health care medicare advantage hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 united health care medicare advantage hmo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 united health care medicare advantage ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 united health care medicare advantage pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 united health care medicare advantage epo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 united health care medicare advantage ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 united health care medicare advantage pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 99.29 99.29 united health care medicare advantage hmo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 388.31 388.31 united health care medicare advantage hmo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 388.31 388.31 united health care medicare advantage ppo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 388.31 388.31 united health care medicare advantage pos dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 388.31 388.31 united health care medicare advantage epo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 388.31 388.31 united health care medicare advantage ppo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 388.31 388.31 united health care medicare advantage pos dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 388.31 388.31 united health care medicare advantage hmo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 759.67 759.67 united health care medicare advantage hmo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 759.67 759.67 united health care medicare advantage ppo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 759.67 759.67 united health care medicare advantage pos leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 759.67 759.67 united health care medicare advantage epo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 759.67 759.67 united health care medicare advantage ppo leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 759.67 759.67 united health care medicare advantage pos leuprolide acetate suspnsion cpt J9217 2006.58 2006.58 266.58 266.58 3210.53 3210.53 2675.44 2675.44 O 759.67 759.67 united health care medicare advantage hmo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 7109.98 7109.98 united health care medicare advantage hmo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 7109.98 7109.98 united health care medicare advantage ppo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 7109.98 7109.98 united health care medicare advantage pos kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 7109.98 7109.98 united health care medicare advantage epo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 7109.98 7109.98 united health care medicare advantage ppo kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 7109.98 7109.98 united health care medicare advantage pos kidney and urinary tract infections with mcc ms-drg 689 10878.75 10878.75 6312.25 6312.25 26935.22 26935.22 22446.02 22446.02 I 7109.98 7109.98 united health care medicare advantage hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 united health care medicare advantage hmo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 united health care medicare advantage ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 united health care medicare advantage pos "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 united health care medicare advantage epo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 united health care medicare advantage ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 united health care medicare advantage pos "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 197.85 197.85 united health care medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2102.95 2102.95 united health care medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2102.95 2102.95 united health care medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2102.95 2102.95 united health care medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2102.95 2102.95 united health care medicare advantage epo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2102.95 2102.95 united health care medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2102.95 2102.95 united health care medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis" cpt 96366 3225.5 3225.5 710.99 710.99 7846.93 7846.93 6539.11 6539.11 E 2102.95 2102.95 united health care medicare advantage hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 4881.58 4881.58 united health care medicare advantage hmo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 4881.58 4881.58 united health care medicare advantage ppo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 4881.58 4881.58 united health care medicare advantage pos Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 4881.58 4881.58 united health care medicare advantage epo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 4881.58 4881.58 united health care medicare advantage ppo Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 4881.58 4881.58 united health care medicare advantage pos Infusion of different chemotherapy drug or substance into a vein up to 1 hour cpt 96417 8152.79 8152.79 4881.58 4881.58 29983.2 29983.2 24986 24986 O 4881.58 4881.58 united health care medicare advantage hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1472.58 1472.58 united health care medicare advantage hmo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1472.58 1472.58 united health care medicare advantage ppo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1472.58 1472.58 united health care medicare advantage pos Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1472.58 1472.58 united health care medicare advantage epo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1472.58 1472.58 united health care medicare advantage ppo Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1472.58 1472.58 united health care medicare advantage pos Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle cpt 96402 2772.2 2772.2 266.58 266.58 8842.94 8842.94 7369.12 7369.12 O 1472.58 1472.58 united health care medicare advantage hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.36 6.36 united health care medicare advantage hmo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.36 6.36 united health care medicare advantage ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.36 6.36 united health care medicare advantage pos Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.36 6.36 united health care medicare advantage epo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.36 6.36 united health care medicare advantage ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.36 6.36 united health care medicare advantage pos Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 6.36 6.36 united health care medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 62.1 62.1 united health care medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 62.1 62.1 united health care medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 62.1 62.1 united health care medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 62.1 62.1 united health care medicare advantage epo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 62.1 62.1 united health care medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 62.1 62.1 united health care medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 62.1 62.1 united health care medicare advantage hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage hmo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage pos dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage epo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage pos dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2075.54 2075.54 united health care medicare advantage hmo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2075.54 2075.54 united health care medicare advantage ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2075.54 2075.54 united health care medicare advantage pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2075.54 2075.54 united health care medicare advantage epo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2075.54 2075.54 united health care medicare advantage ppo "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2075.54 2075.54 united health care medicare advantage pos "Evaluation of physical therapy, typically 45 minutes" cpt 97163 6677.69 6677.69 1054.94 1054.94 16181.48 16181.48 13484.57 13484.57 E 2075.54 2075.54 united health care medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 992.27 992.27 united health care medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 992.27 992.27 united health care medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 992.27 992.27 united health care medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 992.27 992.27 united health care medicare advantage epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 992.27 992.27 united health care medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 992.27 992.27 united health care medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 992.27 992.27 united health care medicare advantage hmo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4547.22 4547.22 united health care medicare advantage hmo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4547.22 4547.22 united health care medicare advantage ppo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4547.22 4547.22 united health care medicare advantage pos Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4547.22 4547.22 united health care medicare advantage epo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4547.22 4547.22 united health care medicare advantage ppo Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4547.22 4547.22 united health care medicare advantage pos Total removal of breast cpt 19303 4639.61 4639.61 4547.22 4547.22 27091.91 27091.91 22576.59 22576.59 O 4547.22 4547.22 united health care medicare advantage hmo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1128.66 1128.66 united health care medicare advantage hmo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1128.66 1128.66 united health care medicare advantage ppo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1128.66 1128.66 united health care medicare advantage pos non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1128.66 1128.66 united health care medicare advantage epo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1128.66 1128.66 united health care medicare advantage ppo non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1128.66 1128.66 united health care medicare advantage pos non-heu tc-99m add-on/dose cpt Q9969 1130.05 1130.05 586.4 586.4 8903.83 8903.83 7419.86 7419.86 O 1128.66 1128.66 united health care medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 69.29 69.29 united health care medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 69.29 69.29 united health care medicare advantage ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 69.29 69.29 united health care medicare advantage pos "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 69.29 69.29 united health care medicare advantage epo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 69.29 69.29 united health care medicare advantage ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 69.29 69.29 united health care medicare advantage pos "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 69.29 69.29 united health care medicare advantage hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 69.71 69.71 united health care medicare advantage hmo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 69.71 69.71 united health care medicare advantage ppo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 69.71 69.71 united health care medicare advantage pos "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 69.71 69.71 united health care medicare advantage epo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 69.71 69.71 united health care medicare advantage ppo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 69.71 69.71 united health care medicare advantage pos "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 69.71 69.71 united health care medicare advantage hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 united health care medicare advantage hmo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 united health care medicare advantage ppo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 united health care medicare advantage pos Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 united health care medicare advantage epo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 united health care medicare advantage ppo Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 united health care medicare advantage pos Nuclear medicine study with CT imaging skull base to mid-thigh cpt 78815 4915.33 4915.33 1196.94 1196.94 7672.7 7672.7 6393.92 6393.92 O 1278.4 1278.4 united health care medicare advantage hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 united health care medicare advantage hmo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 united health care medicare advantage ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 united health care medicare advantage pos Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 united health care medicare advantage epo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 united health care medicare advantage ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 united health care medicare advantage pos Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 5.18 5.18 united health care medicare advantage hmo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 united health care medicare advantage hmo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 united health care medicare advantage ppo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 united health care medicare advantage pos Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 united health care medicare advantage epo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 united health care medicare advantage ppo Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 united health care medicare advantage pos Removal of both knee cartilages using an endoscope cpt 29880 16311.44 16311.44 2252.71 2252.71 22144.92 22144.92 18454.1 18454.1 O 2425.05 2425.05 united health care medicare advantage hmo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14036.18 14036.18 united health care medicare advantage hmo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14036.18 14036.18 united health care medicare advantage ppo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14036.18 14036.18 united health care medicare advantage pos embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14036.18 14036.18 united health care medicare advantage epo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14036.18 14036.18 united health care medicare advantage ppo embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14036.18 14036.18 united health care medicare advantage pos embolization protect syst cpt C1884 14120.9 14120.9 8185.32 8185.32 75631.02 75631.02 63025.85 63025.85 O 14036.18 14036.18 united health care medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1067.2 1067.2 united health care medicare advantage hmo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1067.2 1067.2 united health care medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1067.2 1067.2 united health care medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1067.2 1067.2 united health care medicare advantage epo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1067.2 1067.2 united health care medicare advantage ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1067.2 1067.2 united health care medicare advantage pos "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1067.2 1067.2 united health care medicare advantage hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 2440.04 2440.04 united health care medicare advantage hmo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 2440.04 2440.04 united health care medicare advantage ppo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 2440.04 2440.04 united health care medicare advantage pos hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 2440.04 2440.04 united health care medicare advantage epo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 2440.04 2440.04 united health care medicare advantage ppo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 2440.04 2440.04 united health care medicare advantage pos hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 2440.04 2440.04 united health care medicare advantage hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 13951.45 13951.45 united health care medicare advantage hmo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 13951.45 13951.45 united health care medicare advantage ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 13951.45 13951.45 united health care medicare advantage pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 13951.45 13951.45 united health care medicare advantage epo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 13951.45 13951.45 united health care medicare advantage ppo "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 13951.45 13951.45 united health care medicare advantage pos "Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes" cpt 99152 16039.46 16039.46 2411.79 2411.79 26116.43 26116.43 21763.69 21763.69 O 13951.45 13951.45 united health care medicare advantage hmo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 united health care medicare advantage hmo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 united health care medicare advantage ppo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 united health care medicare advantage pos "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 united health care medicare advantage epo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 united health care medicare advantage ppo "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 united health care medicare advantage pos "cath, trans atherec,rotation" cpt C1724 14120.9 14120.9 14120.9 14120.9 119615.33 119615.33 99679.44 99679.44 O 14120.9 14120.9 united health care medicare advantage hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 united health care medicare advantage hmo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 united health care medicare advantage ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 united health care medicare advantage pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 united health care medicare advantage epo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 united health care medicare advantage ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 united health care medicare advantage pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 8.07 8.07 united health care medicare advantage hmo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1952.13 1952.13 united health care medicare advantage hmo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1952.13 1952.13 united health care medicare advantage ppo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1952.13 1952.13 united health care medicare advantage pos diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1952.13 1952.13 united health care medicare advantage epo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1952.13 1952.13 united health care medicare advantage ppo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1952.13 1952.13 united health care medicare advantage pos diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 1952.13 1952.13 united health care medicare advantage hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 770.82 770.82 united health care medicare advantage hmo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 770.82 770.82 united health care medicare advantage ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 770.82 770.82 united health care medicare advantage pos Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 770.82 770.82 united health care medicare advantage epo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 770.82 770.82 united health care medicare advantage ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 770.82 770.82 united health care medicare advantage pos Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 770.82 770.82 united health care medicare advantage hmo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2082.23 2082.23 united health care medicare advantage hmo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2082.23 2082.23 united health care medicare advantage ppo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2082.23 2082.23 united health care medicare advantage pos Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2082.23 2082.23 united health care medicare advantage epo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2082.23 2082.23 united health care medicare advantage ppo Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2082.23 2082.23 united health care medicare advantage pos Evaluation of swallowing function cpt 92610 2136.63 2136.63 869.58 869.58 17501.99 17501.99 14584.99 14584.99 E 2082.23 2082.23 united health care medicare advantage hmo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 4881.58 4881.58 united health care medicare advantage hmo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 4881.58 4881.58 united health care medicare advantage ppo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 4881.58 4881.58 united health care medicare advantage pos etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 4881.58 4881.58 united health care medicare advantage epo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 4881.58 4881.58 united health care medicare advantage ppo etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 4881.58 4881.58 united health care medicare advantage pos etoposide injection cpt J9181 5489.65 5489.65 299.23 299.23 26754.95 26754.95 22295.79 22295.79 O 4881.58 4881.58 united health care medicare advantage hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 29.78 29.78 united health care medicare advantage hmo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 29.78 29.78 united health care medicare advantage ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 29.78 29.78 united health care medicare advantage pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 29.78 29.78 united health care medicare advantage epo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 29.78 29.78 united health care medicare advantage ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 29.78 29.78 united health care medicare advantage pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 29.78 29.78 united health care medicare advantage hmo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 6154.82 6154.82 united health care medicare advantage hmo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 6154.82 6154.82 united health care medicare advantage ppo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 6154.82 6154.82 united health care medicare advantage pos complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 6154.82 6154.82 united health care medicare advantage epo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 6154.82 6154.82 united health care medicare advantage ppo complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 6154.82 6154.82 united health care medicare advantage pos complications of treatment with cc ms-drg 920 10317.22 10317.22 3798.86 3798.86 15884.95 15884.95 13237.46 13237.46 I 6154.82 6154.82 united health care medicare advantage hmo hypertension with mcc ms-drg 304 7313.51 7313.51 4015.28 4015.28 32827.03 32827.03 27355.86 27355.86 I 5197.6 5197.6 united health care medicare advantage hmo hypertension with mcc ms-drg 304 7313.51 7313.51 4015.28 4015.28 32827.03 32827.03 27355.86 27355.86 I 5197.6 5197.6 united health care medicare advantage ppo hypertension with mcc ms-drg 304 7313.51 7313.51 4015.28 4015.28 32827.03 32827.03 27355.86 27355.86 I 5197.6 5197.6 united health care medicare advantage pos hypertension with mcc ms-drg 304 7313.51 7313.51 4015.28 4015.28 32827.03 32827.03 27355.86 27355.86 I 5197.6 5197.6 united health care medicare advantage epo hypertension with mcc ms-drg 304 7313.51 7313.51 4015.28 4015.28 32827.03 32827.03 27355.86 27355.86 I 5197.6 5197.6 united health care medicare advantage ppo hypertension with mcc ms-drg 304 7313.51 7313.51 4015.28 4015.28 32827.03 32827.03 27355.86 27355.86 I 5197.6 5197.6 united health care medicare advantage pos hypertension with mcc ms-drg 304 7313.51 7313.51 4015.28 4015.28 32827.03 32827.03 27355.86 27355.86 I 5197.6 5197.6 united health care medicare advantage hmo "cath, thrombectomy/embolect" cpt C1757 13951.45 13951.45 8630.33 8630.33 38902.45 38902.45 32418.71 32418.71 O 13951.45 13951.45 united health care medicare advantage hmo "cath, thrombectomy/embolect" cpt C1757 13951.45 13951.45 8630.33 8630.33 38902.45 38902.45 32418.71 32418.71 O 13951.45 13951.45 united health care medicare advantage ppo "cath, thrombectomy/embolect" cpt C1757 13951.45 13951.45 8630.33 8630.33 38902.45 38902.45 32418.71 32418.71 O 13951.45 13951.45 united health care medicare advantage pos "cath, thrombectomy/embolect" cpt C1757 13951.45 13951.45 8630.33 8630.33 38902.45 38902.45 32418.71 32418.71 O 13951.45 13951.45 united health care medicare advantage epo "cath, thrombectomy/embolect" cpt C1757 13951.45 13951.45 8630.33 8630.33 38902.45 38902.45 32418.71 32418.71 O 13951.45 13951.45 united health care medicare advantage ppo "cath, thrombectomy/embolect" cpt C1757 13951.45 13951.45 8630.33 8630.33 38902.45 38902.45 32418.71 32418.71 O 13951.45 13951.45 united health care medicare advantage pos "cath, thrombectomy/embolect" cpt C1757 13951.45 13951.45 8630.33 8630.33 38902.45 38902.45 32418.71 32418.71 O 13951.45 13951.45 united health care medicare advantage hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4906.66 4906.66 united health care medicare advantage hmo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4906.66 4906.66 united health care medicare advantage ppo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4906.66 4906.66 united health care medicare advantage pos cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4906.66 4906.66 united health care medicare advantage epo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4906.66 4906.66 united health care medicare advantage ppo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4906.66 4906.66 united health care medicare advantage pos cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 4906.66 4906.66 united health care medicare advantage hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1965.52 1965.52 united health care medicare advantage hmo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1965.52 1965.52 united health care medicare advantage ppo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1965.52 1965.52 united health care medicare advantage pos diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1965.52 1965.52 united health care medicare advantage epo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1965.52 1965.52 united health care medicare advantage ppo diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1965.52 1965.52 united health care medicare advantage pos diphenhydramine hcl injectio cpt J1200 17916.14 17916.14 474.34 474.34 16100.98 16100.98 13417.48 13417.48 O 1965.52 1965.52 united health care medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 united health care medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 united health care medicare advantage ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 united health care medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 united health care medicare advantage epo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 united health care medicare advantage ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 united health care medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 10.56 10.56 united health care medicare advantage hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1379.67 1379.67 united health care medicare advantage hmo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1379.67 1379.67 united health care medicare advantage ppo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1379.67 1379.67 united health care medicare advantage pos "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1379.67 1379.67 united health care medicare advantage epo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1379.67 1379.67 united health care medicare advantage ppo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1379.67 1379.67 united health care medicare advantage pos "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 1379.67 1379.67 united health care medicare advantage hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 536.02 536.02 united health care medicare advantage hmo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 536.02 536.02 united health care medicare advantage ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 536.02 536.02 united health care medicare advantage pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 536.02 536.02 united health care medicare advantage epo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 536.02 536.02 united health care medicare advantage ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 536.02 536.02 united health care medicare advantage pos Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 536.02 536.02 united health care medicare advantage hmo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 united health care medicare advantage hmo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 united health care medicare advantage ppo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 united health care medicare advantage pos CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 united health care medicare advantage epo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 united health care medicare advantage ppo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 united health care medicare advantage pos CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 99.29 99.29 united health care medicare advantage hmo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 158.53 158.53 united health care medicare advantage hmo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 158.53 158.53 united health care medicare advantage ppo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 158.53 158.53 united health care medicare advantage pos X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 158.53 158.53 united health care medicare advantage epo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 158.53 158.53 united health care medicare advantage ppo X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 158.53 158.53 united health care medicare advantage pos X-ray of large bowel with air contrast cpt 74280 318.52 318.52 158.53 158.53 1001.06 1001.06 834.22 834.22 O 158.53 158.53 united health care medicare advantage hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 united health care medicare advantage hmo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 united health care medicare advantage ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 united health care medicare advantage pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 united health care medicare advantage epo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 united health care medicare advantage ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 united health care medicare advantage pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 9.02 9.02 united health care medicare advantage hmo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 13951.45 13951.45 united health care medicare advantage hmo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 13951.45 13951.45 united health care medicare advantage ppo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 13951.45 13951.45 united health care medicare advantage pos "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 13951.45 13951.45 united health care medicare advantage epo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 13951.45 13951.45 united health care medicare advantage ppo "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 13951.45 13951.45 united health care medicare advantage pos "cath, trans atherectomy, dir" cpt C1714 14120.9 14120.9 11449.31 11449.31 97804.18 97804.18 81503.48 81503.48 O 13951.45 13951.45 united health care medicare advantage hmo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 992.27 992.27 united health care medicare advantage hmo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 992.27 992.27 united health care medicare advantage ppo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 992.27 992.27 united health care medicare advantage pos inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 992.27 992.27 united health care medicare advantage epo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 992.27 992.27 united health care medicare advantage ppo inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 992.27 992.27 united health care medicare advantage pos inj ferric carboxymaltos 1mg cpt J1439 2651.78 2651.78 763.52 763.52 4104.74 4104.74 3420.62 3420.62 O 992.27 992.27 united health care medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1067.2 1067.2 united health care medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1067.2 1067.2 united health care medicare advantage ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1067.2 1067.2 united health care medicare advantage pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1067.2 1067.2 united health care medicare advantage epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1067.2 1067.2 united health care medicare advantage ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1067.2 1067.2 united health care medicare advantage pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 1067.2 1067.2 united health care medicare advantage hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 69.29 69.29 united health care medicare advantage hmo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 69.29 69.29 united health care medicare advantage ppo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 69.29 69.29 united health care medicare advantage pos "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 69.29 69.29 united health care medicare advantage epo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 69.29 69.29 united health care medicare advantage ppo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 69.29 69.29 united health care medicare advantage pos "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 69.29 69.29 united health care medicare advantage hmo Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 united health care medicare advantage hmo Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 united health care medicare advantage ppo Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 united health care medicare advantage pos Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 united health care medicare advantage epo Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 united health care medicare advantage ppo Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 united health care medicare advantage pos Removal of joint lining from two or more knee joint compartments using an endoscope cpt 29876 2425.05 2425.05 2425.05 2425.05 21015.66 21015.66 17513.05 17513.05 O 2425.05 2425.05 united health care medicare advantage hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage hmo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1032.79 1032.79 united health care medicare advantage hmo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1032.79 1032.79 united health care medicare advantage ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1032.79 1032.79 united health care medicare advantage pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1032.79 1032.79 united health care medicare advantage epo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1032.79 1032.79 united health care medicare advantage ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1032.79 1032.79 united health care medicare advantage pos Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 1032.79 1032.79 united health care medicare advantage hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 united health care medicare advantage hmo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 united health care medicare advantage ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 united health care medicare advantage pos Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 united health care medicare advantage epo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 united health care medicare advantage ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 united health care medicare advantage pos Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 8.74 8.74 united health care medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1267.16 1267.16 united health care medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1267.16 1267.16 united health care medicare advantage ppo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1267.16 1267.16 united health care medicare advantage pos Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1267.16 1267.16 united health care medicare advantage epo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1267.16 1267.16 united health care medicare advantage ppo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1267.16 1267.16 united health care medicare advantage pos Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 1267.16 1267.16 united health care medicare advantage hmo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 united health care medicare advantage hmo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 united health care medicare advantage ppo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 united health care medicare advantage pos "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 united health care medicare advantage epo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 united health care medicare advantage ppo "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 united health care medicare advantage pos "Measurement of complement (immune system proteins), total hemolytic" cpt 86162 20.32 20.32 18.07 18.07 149.56 149.56 124.63 124.63 O 20.32 20.32 united health care medicare advantage hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 united health care medicare advantage hmo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 united health care medicare advantage ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 united health care medicare advantage pos "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 united health care medicare advantage epo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 united health care medicare advantage ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 united health care medicare advantage pos "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 2.7 2.7 united health care medicare advantage hmo "Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin, initial vessel" cpt 37184 13951.45 13951.45 13951.45 13951.45 162973.19 162973.19 135810.99 135810.99 O 13951.45 13951.45 united health care medicare advantage hmo "Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin, initial vessel" cpt 37184 13951.45 13951.45 13951.45 13951.45 162973.19 162973.19 135810.99 135810.99 O 13951.45 13951.45 united health care medicare advantage ppo "Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin, initial vessel" cpt 37184 13951.45 13951.45 13951.45 13951.45 162973.19 162973.19 135810.99 135810.99 O 13951.45 13951.45 united health care medicare advantage pos "Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin, initial vessel" cpt 37184 13951.45 13951.45 13951.45 13951.45 162973.19 162973.19 135810.99 135810.99 O 13951.45 13951.45 united health care medicare advantage epo "Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin, initial vessel" cpt 37184 13951.45 13951.45 13951.45 13951.45 162973.19 162973.19 135810.99 135810.99 O 13951.45 13951.45 united health care medicare advantage ppo "Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin, initial vessel" cpt 37184 13951.45 13951.45 13951.45 13951.45 162973.19 162973.19 135810.99 135810.99 O 13951.45 13951.45 united health care medicare advantage pos "Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin, initial vessel" cpt 37184 13951.45 13951.45 13951.45 13951.45 162973.19 162973.19 135810.99 135810.99 O 13951.45 13951.45 united health care medicare advantage hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 united health care medicare advantage hmo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 united health care medicare advantage ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 united health care medicare advantage pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 united health care medicare advantage epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 united health care medicare advantage ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 united health care medicare advantage pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 5.18 5.18 united health care medicare advantage hmo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 4881.58 4881.58 united health care medicare advantage hmo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 4881.58 4881.58 united health care medicare advantage ppo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 4881.58 4881.58 united health care medicare advantage pos carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 4881.58 4881.58 united health care medicare advantage epo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 4881.58 4881.58 united health care medicare advantage ppo carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 4881.58 4881.58 united health care medicare advantage pos carboplatin injection cpt J9045 23772.44 23772.44 1279.57 1279.57 25273.42 25273.42 21061.18 21061.18 O 4881.58 4881.58 united health care medicare advantage hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4881.58 4881.58 united health care medicare advantage hmo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4881.58 4881.58 united health care medicare advantage ppo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4881.58 4881.58 united health care medicare advantage pos fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4881.58 4881.58 united health care medicare advantage epo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4881.58 4881.58 united health care medicare advantage ppo fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4881.58 4881.58 united health care medicare advantage pos fosaprepitant injection cpt J1453 7649.74 7649.74 2286.87 2286.87 24852.24 24852.24 20710.2 20710.2 O 4881.58 4881.58 united health care medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 united health care medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 united health care medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 united health care medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 united health care medicare advantage epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 united health care medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 united health care medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 6.47 6.47 united health care medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 415.61 415.61 united health care medicare advantage hmo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 415.61 415.61 united health care medicare advantage ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 415.61 415.61 united health care medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 415.61 415.61 united health care medicare advantage epo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 415.61 415.61 united health care medicare advantage ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 415.61 415.61 united health care medicare advantage pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 415.61 415.61 united health care medicare advantage hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage hmo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage ppo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage pos palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage epo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage ppo palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage pos palonosetron hcl cpt J2469 9805.54 9805.54 2458.54 2458.54 22005.6 22005.6 18338 18338 O 4881.58 4881.58 united health care medicare advantage hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 united health care medicare advantage hmo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 united health care medicare advantage ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 united health care medicare advantage pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 united health care medicare advantage epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 united health care medicare advantage ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 united health care medicare advantage pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 16.8 16.8 united health care medicare advantage hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1965.52 1965.52 united health care medicare advantage hmo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1965.52 1965.52 united health care medicare advantage ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1965.52 1965.52 united health care medicare advantage pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1965.52 1965.52 united health care medicare advantage epo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1965.52 1965.52 united health care medicare advantage ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1965.52 1965.52 united health care medicare advantage pos Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 1965.52 1965.52 united health care medicare advantage hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 united health care medicare advantage hmo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 united health care medicare advantage ppo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 united health care medicare advantage pos "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 united health care medicare advantage epo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 united health care medicare advantage ppo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 united health care medicare advantage pos "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 4282.09 4282.09 united health care medicare advantage hmo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 5064.95 5064.95 united health care medicare advantage hmo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 5064.95 5064.95 united health care medicare advantage ppo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 5064.95 5064.95 united health care medicare advantage pos kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 5064.95 5064.95 united health care medicare advantage epo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 5064.95 5064.95 united health care medicare advantage ppo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 5064.95 5064.95 united health care medicare advantage pos kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 5064.95 5064.95 united health care medicare advantage hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 united health care medicare advantage hmo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 united health care medicare advantage ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 united health care medicare advantage pos "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 united health care medicare advantage epo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 united health care medicare advantage ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 united health care medicare advantage pos "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 70.7 70.7 united health care medicare advantage hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 united health care medicare advantage hmo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 united health care medicare advantage ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 united health care medicare advantage pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 united health care medicare advantage epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 united health care medicare advantage ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 united health care medicare advantage pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 united health care medicare advantage hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 97.9 97.9 united health care medicare advantage hmo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 97.9 97.9 united health care medicare advantage ppo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 97.9 97.9 united health care medicare advantage pos CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 97.9 97.9 united health care medicare advantage epo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 97.9 97.9 united health care medicare advantage ppo CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 97.9 97.9 united health care medicare advantage pos CT scan head or brain cpt 70450 1642.08 1642.08 13.89 13.89 2644.49 2644.49 2203.74 2203.74 O 97.9 97.9 united health care medicare advantage hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 13951.45 13951.45 united health care medicare advantage hmo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 13951.45 13951.45 united health care medicare advantage ppo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 13951.45 13951.45 united health care medicare advantage pos "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 13951.45 13951.45 united health care medicare advantage epo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 13951.45 13951.45 united health care medicare advantage ppo "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 13951.45 13951.45 united health care medicare advantage pos "Moderate sedation services by physician also performing a procedure, additional 15 minutes" cpt 99153 16039.46 16039.46 2411.79 2411.79 24539.93 24539.93 20449.94 20449.94 O 13951.45 13951.45 united health care medicare advantage hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2455.02 2455.02 united health care medicare advantage hmo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2455.02 2455.02 united health care medicare advantage ppo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2455.02 2455.02 united health care medicare advantage pos ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2455.02 2455.02 united health care medicare advantage epo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2455.02 2455.02 united health care medicare advantage ppo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2455.02 2455.02 united health care medicare advantage pos ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 2455.02 2455.02 united health care medicare advantage hmo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 770.82 770.82 united health care medicare advantage hmo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 770.82 770.82 united health care medicare advantage ppo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 770.82 770.82 united health care medicare advantage pos ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 770.82 770.82 united health care medicare advantage epo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 770.82 770.82 united health care medicare advantage ppo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 770.82 770.82 united health care medicare advantage pos ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 770.82 770.82 united health care medicare advantage hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4881.58 4881.58 united health care medicare advantage hmo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4881.58 4881.58 united health care medicare advantage ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4881.58 4881.58 united health care medicare advantage pos Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4881.58 4881.58 united health care medicare advantage epo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4881.58 4881.58 united health care medicare advantage ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4881.58 4881.58 united health care medicare advantage pos Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 4881.58 4881.58 united health care medicare advantage hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2116.34 2116.34 united health care medicare advantage hmo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2116.34 2116.34 united health care medicare advantage ppo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2116.34 2116.34 united health care medicare advantage pos "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2116.34 2116.34 united health care medicare advantage epo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2116.34 2116.34 united health care medicare advantage ppo "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2116.34 2116.34 united health care medicare advantage pos "Evaluation of physical therapy, typically 30 minutes" cpt 97162 2116.34 2116.34 2041.43 2041.43 17108.82 17108.82 14257.35 14257.35 E 2116.34 2116.34 united health care medicare advantage hmo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2048.12 2048.12 united health care medicare advantage hmo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2048.12 2048.12 united health care medicare advantage ppo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2048.12 2048.12 united health care medicare advantage pos acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2048.12 2048.12 united health care medicare advantage epo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2048.12 2048.12 united health care medicare advantage ppo acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2048.12 2048.12 united health care medicare advantage pos acetaminophen injection cpt J0131 21270.9 21270.9 720.95 720.95 9509.64 9509.64 7924.7 7924.7 E 2048.12 2048.12 united health care medicare advantage hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage hmo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage pos inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage epo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage pos inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 205.21 205.21 united health care medicare advantage hmo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 205.21 205.21 united health care medicare advantage ppo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 205.21 205.21 united health care medicare advantage pos "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 205.21 205.21 united health care medicare advantage epo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 205.21 205.21 united health care medicare advantage ppo "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 205.21 205.21 united health care medicare advantage pos "Radiation treatment delivery, complex" cpt 77412 660.29 660.29 205.21 205.21 1006.15 1006.15 838.46 838.46 O 205.21 205.21 united health care medicare advantage hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 united health care medicare advantage hmo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 united health care medicare advantage ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 united health care medicare advantage pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 united health care medicare advantage epo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 united health care medicare advantage ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 united health care medicare advantage pos Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 8.08 8.08 united health care medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 united health care medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 united health care medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 united health care medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 united health care medicare advantage epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 united health care medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 united health care medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 10082.72 10082.72 1489.46 1489.46 18299.95 18299.95 15249.96 15249.96 E 1965.52 1965.52 united health care medicare advantage hmo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 2116.34 2116.34 united health care medicare advantage hmo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 2116.34 2116.34 united health care medicare advantage ppo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 2116.34 2116.34 united health care medicare advantage pos inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 2116.34 2116.34 united health care medicare advantage epo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 2116.34 2116.34 united health care medicare advantage ppo inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 2116.34 2116.34 united health care medicare advantage pos inj heparin sodium per 1000u cpt J1644 23096.99 23096.99 1153.4 1153.4 14665.32 14665.32 12221.1 12221.1 E 2116.34 2116.34 united health care medicare advantage hmo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5559.48 5559.48 united health care medicare advantage hmo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5559.48 5559.48 united health care medicare advantage ppo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5559.48 5559.48 united health care medicare advantage pos transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5559.48 5559.48 united health care medicare advantage epo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5559.48 5559.48 united health care medicare advantage ppo transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5559.48 5559.48 united health care medicare advantage pos transient ischemia without thrombolytic ms-drg 69 5809.49 5809.49 4000.83 4000.83 27147.31 27147.31 22622.76 22622.76 I 5559.48 5559.48 united health care medicare advantage hmo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 13951.45 13951.45 united health care medicare advantage hmo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 13951.45 13951.45 united health care medicare advantage ppo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 13951.45 13951.45 united health care medicare advantage pos "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 13951.45 13951.45 united health care medicare advantage epo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 13951.45 13951.45 united health care medicare advantage ppo "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 13951.45 13951.45 united health care medicare advantage pos "Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure" cpt 37227 14120.9 14120.9 13053.92 13053.92 119615.33 119615.33 99679.44 99679.44 O 13951.45 13951.45 united health care medicare advantage hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 united health care medicare advantage hmo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 united health care medicare advantage ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 united health care medicare advantage pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 united health care medicare advantage epo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 united health care medicare advantage ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 united health care medicare advantage pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 2.25 2.25 united health care medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 676.44 676.44 united health care medicare advantage hmo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 676.44 676.44 united health care medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 676.44 676.44 united health care medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 676.44 676.44 united health care medicare advantage epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 676.44 676.44 united health care medicare advantage ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 676.44 676.44 united health care medicare advantage pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 676.44 676.44 united health care medicare advantage hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 united health care medicare advantage hmo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 united health care medicare advantage ppo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 united health care medicare advantage pos phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 united health care medicare advantage epo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 united health care medicare advantage ppo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 united health care medicare advantage pos phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 4282.09 4282.09 united health care medicare advantage hmo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 8238.08 8238.08 united health care medicare advantage hmo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 8238.08 8238.08 united health care medicare advantage ppo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 8238.08 8238.08 united health care medicare advantage pos inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 8238.08 8238.08 united health care medicare advantage epo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 8238.08 8238.08 united health care medicare advantage ppo inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 8238.08 8238.08 united health care medicare advantage pos inj heparin sodium per 1000u cpt J1644 16160.85 16160.85 2489.54 2489.54 24660.7 24660.7 20550.58 20550.58 O 8238.08 8238.08 united health care medicare advantage hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 united health care medicare advantage hmo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 united health care medicare advantage ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 united health care medicare advantage pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 united health care medicare advantage epo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 united health care medicare advantage ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 united health care medicare advantage pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 206.45 206.45 united health care medicare advantage hmo fractures of hip and pelvis without mcc ms-drg 536 5056.63 5056.63 4866.91 4866.91 16940.58 16940.58 14117.15 14117.15 I 4866.91 4866.91 united health care medicare advantage hmo fractures of hip and pelvis without mcc ms-drg 536 5056.63 5056.63 4866.91 4866.91 16940.58 16940.58 14117.15 14117.15 I 4866.91 4866.91 united health care medicare advantage ppo fractures of hip and pelvis without mcc ms-drg 536 5056.63 5056.63 4866.91 4866.91 16940.58 16940.58 14117.15 14117.15 I 4866.91 4866.91 united health care medicare advantage pos fractures of hip and pelvis without mcc ms-drg 536 5056.63 5056.63 4866.91 4866.91 16940.58 16940.58 14117.15 14117.15 I 4866.91 4866.91 united health care medicare advantage epo fractures of hip and pelvis without mcc ms-drg 536 5056.63 5056.63 4866.91 4866.91 16940.58 16940.58 14117.15 14117.15 I 4866.91 4866.91 united health care medicare advantage ppo fractures of hip and pelvis without mcc ms-drg 536 5056.63 5056.63 4866.91 4866.91 16940.58 16940.58 14117.15 14117.15 I 4866.91 4866.91 united health care medicare advantage pos fractures of hip and pelvis without mcc ms-drg 536 5056.63 5056.63 4866.91 4866.91 16940.58 16940.58 14117.15 14117.15 I 4866.91 4866.91 united health care medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.09 70.09 united health care medicare advantage hmo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.09 70.09 united health care medicare advantage ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.09 70.09 united health care medicare advantage pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.09 70.09 united health care medicare advantage epo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.09 70.09 united health care medicare advantage ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.09 70.09 united health care medicare advantage pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 70.09 70.09 united health care medicare advantage hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 2102.95 2102.95 united health care medicare advantage hmo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 2102.95 2102.95 united health care medicare advantage ppo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 2102.95 2102.95 united health care medicare advantage pos inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 2102.95 2102.95 united health care medicare advantage epo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 2102.95 2102.95 united health care medicare advantage ppo inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 2102.95 2102.95 united health care medicare advantage pos inj enoxaparin sodium cpt J1650 8278.58 8278.58 1189.42 1189.42 15756.58 15756.58 13130.48 13130.48 E 2102.95 2102.95 united health care medicare advantage hmo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 388.31 388.31 united health care medicare advantage hmo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 388.31 388.31 united health care medicare advantage ppo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 388.31 388.31 united health care medicare advantage pos orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 388.31 388.31 united health care medicare advantage epo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 388.31 388.31 united health care medicare advantage ppo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 388.31 388.31 united health care medicare advantage pos orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 388.31 388.31 united health care medicare advantage hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 united health care medicare advantage hmo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 united health care medicare advantage ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 united health care medicare advantage pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 united health care medicare advantage epo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 united health care medicare advantage ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 united health care medicare advantage pos Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 1108.98 1108.98 united health care medicare advantage hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1128.66 1128.66 united health care medicare advantage hmo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1128.66 1128.66 united health care medicare advantage ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1128.66 1128.66 united health care medicare advantage pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1128.66 1128.66 united health care medicare advantage epo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1128.66 1128.66 united health care medicare advantage ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1128.66 1128.66 united health care medicare advantage pos tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1128.66 1128.66 united health care medicare advantage hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 13951.45 13951.45 united health care medicare advantage hmo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 13951.45 13951.45 united health care medicare advantage ppo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 13951.45 13951.45 united health care medicare advantage pos morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 13951.45 13951.45 united health care medicare advantage epo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 13951.45 13951.45 united health care medicare advantage ppo morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 13951.45 13951.45 united health care medicare advantage pos morphine sulfate injection cpt J2270 19270.59 19270.59 689 689 13027.27 13027.27 10856.06 10856.06 O 13951.45 13951.45 united health care medicare advantage hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 united health care medicare advantage hmo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 united health care medicare advantage ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 united health care medicare advantage pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 united health care medicare advantage epo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 united health care medicare advantage ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 united health care medicare advantage pos "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 8.65 8.65 united health care medicare advantage hmo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 2048.12 2048.12 united health care medicare advantage hmo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 2048.12 2048.12 united health care medicare advantage ppo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 2048.12 2048.12 united health care medicare advantage pos prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 2048.12 2048.12 united health care medicare advantage epo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 2048.12 2048.12 united health care medicare advantage ppo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 2048.12 2048.12 united health care medicare advantage pos prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 2048.12 2048.12 united health care medicare advantage hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 710.37 710.37 united health care medicare advantage hmo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 710.37 710.37 united health care medicare advantage ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 710.37 710.37 united health care medicare advantage pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 710.37 710.37 united health care medicare advantage epo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 710.37 710.37 united health care medicare advantage ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 710.37 710.37 united health care medicare advantage pos "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 710.37 710.37 united health care medicare advantage hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 11468.13 11468.13 united health care medicare advantage hmo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 11468.13 11468.13 united health care medicare advantage ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 11468.13 11468.13 united health care medicare advantage pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 11468.13 11468.13 united health care medicare advantage epo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 11468.13 11468.13 united health care medicare advantage ppo septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 11468.13 11468.13 united health care medicare advantage pos septicemia or severe sepsis with mv >96 hours ms-drg 870 127330.68 127330.68 11468.13 11468.13 196722.26 196722.26 163935.22 163935.22 I 11468.13 11468.13 united health care medicare advantage hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 united health care medicare advantage hmo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 united health care medicare advantage ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 united health care medicare advantage pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 united health care medicare advantage epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 united health care medicare advantage ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 united health care medicare advantage pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 8.46 8.46 united health care medicare advantage hmo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 31.47 31.47 united health care medicare advantage hmo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 31.47 31.47 united health care medicare advantage ppo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 31.47 31.47 united health care medicare advantage pos "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 31.47 31.47 united health care medicare advantage epo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 31.47 31.47 united health care medicare advantage ppo "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 31.47 31.47 united health care medicare advantage pos "Evaluation of parameters of leadless, single, dual, or multiple lead pacemaker system with qualified health care professional analysis, review, and report" cpt 93288 215.45 215.45 31.47 31.47 344.71 344.71 287.26 287.26 O 31.47 31.47 united health care medicare advantage hmo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 13951.45 13951.45 united health care medicare advantage hmo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 13951.45 13951.45 united health care medicare advantage ppo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 13951.45 13951.45 united health care medicare advantage pos "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 13951.45 13951.45 united health care medicare advantage epo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 13951.45 13951.45 united health care medicare advantage ppo "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 13951.45 13951.45 united health care medicare advantage pos "Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure" cpt 37228 14120.9 14120.9 11383.48 11383.48 92185.34 92185.34 76821.12 76821.12 O 13951.45 13951.45 united health care medicare advantage hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 13951.45 13951.45 united health care medicare advantage hmo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 13951.45 13951.45 united health care medicare advantage ppo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 13951.45 13951.45 united health care medicare advantage pos "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 13951.45 13951.45 united health care medicare advantage epo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 13951.45 13951.45 united health care medicare advantage ppo "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 13951.45 13951.45 united health care medicare advantage pos "intro/sheath, non-laser" cpt C1894 16160.85 16160.85 2524.71 2524.71 31247.75 31247.75 26039.79 26039.79 O 13951.45 13951.45 united health care medicare advantage hmo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 829.53 829.53 united health care medicare advantage hmo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 829.53 829.53 united health care medicare advantage ppo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 829.53 829.53 united health care medicare advantage pos morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 829.53 829.53 united health care medicare advantage epo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 829.53 829.53 united health care medicare advantage ppo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 829.53 829.53 united health care medicare advantage pos morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 829.53 829.53 united health care medicare advantage hmo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 388.31 388.31 united health care medicare advantage hmo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 388.31 388.31 united health care medicare advantage ppo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 388.31 388.31 united health care medicare advantage pos ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 388.31 388.31 united health care medicare advantage epo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 388.31 388.31 united health care medicare advantage ppo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 388.31 388.31 united health care medicare advantage pos ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 388.31 388.31 united health care medicare advantage hmo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 united health care medicare advantage hmo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 united health care medicare advantage ppo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 united health care medicare advantage pos Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 united health care medicare advantage epo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 united health care medicare advantage ppo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 united health care medicare advantage pos Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 206.45 206.45 united health care medicare advantage hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 united health care medicare advantage hmo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 united health care medicare advantage ppo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 united health care medicare advantage pos inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 united health care medicare advantage epo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 united health care medicare advantage ppo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 united health care medicare advantage pos inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 2524.71 2524.71 united health care medicare advantage hmo "Removal of plaque in artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37229 14120.9 14120.9 14120.9 14120.9 97473.85 97473.85 81228.21 81228.21 O 14120.9 14120.9 united health care medicare advantage hmo "Removal of plaque in artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37229 14120.9 14120.9 14120.9 14120.9 97473.85 97473.85 81228.21 81228.21 O 14120.9 14120.9 united health care medicare advantage ppo "Removal of plaque in artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37229 14120.9 14120.9 14120.9 14120.9 97473.85 97473.85 81228.21 81228.21 O 14120.9 14120.9 united health care medicare advantage pos "Removal of plaque in artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37229 14120.9 14120.9 14120.9 14120.9 97473.85 97473.85 81228.21 81228.21 O 14120.9 14120.9 united health care medicare advantage epo "Removal of plaque in artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37229 14120.9 14120.9 14120.9 14120.9 97473.85 97473.85 81228.21 81228.21 O 14120.9 14120.9 united health care medicare advantage ppo "Removal of plaque in artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37229 14120.9 14120.9 14120.9 14120.9 97473.85 97473.85 81228.21 81228.21 O 14120.9 14120.9 united health care medicare advantage pos "Removal of plaque in artery in one leg, endovascular, accessed through the skin or open procedure" cpt 37229 14120.9 14120.9 14120.9 14120.9 97473.85 97473.85 81228.21 81228.21 O 14120.9 14120.9 united health care medicare advantage hmo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 13951.45 13951.45 united health care medicare advantage hmo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 13951.45 13951.45 united health care medicare advantage ppo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 13951.45 13951.45 united health care medicare advantage pos "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 13951.45 13951.45 united health care medicare advantage epo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 13951.45 13951.45 united health care medicare advantage ppo "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 13951.45 13951.45 united health care medicare advantage pos "stent, non-coa/non-cov w/del" cpt C1876 14120.9 14120.9 2674.06 2674.06 69550.22 69550.22 57958.52 57958.52 O 13951.45 13951.45 united health care medicare advantage hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 united health care medicare advantage hmo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 united health care medicare advantage ppo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 united health care medicare advantage pos "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 united health care medicare advantage epo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 united health care medicare advantage ppo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 united health care medicare advantage pos "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 14.18 14.18 united health care medicare advantage hmo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 united health care medicare advantage hmo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 united health care medicare advantage ppo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 united health care medicare advantage pos absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 united health care medicare advantage epo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 united health care medicare advantage ppo absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 united health care medicare advantage pos absorpt drg >16 <=48 w/o bdr cpt A6252 278.52 278.52 100.65 100.65 1273.49 1273.49 1061.24 1061.24 O 100.65 100.65 united health care medicare advantage hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 202.33 202.33 united health care medicare advantage hmo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 202.33 202.33 united health care medicare advantage ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 202.33 202.33 united health care medicare advantage pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 202.33 202.33 united health care medicare advantage epo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 202.33 202.33 united health care medicare advantage ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 202.33 202.33 united health care medicare advantage pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 202.33 202.33 united health care medicare advantage hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 2425.05 2425.05 united health care medicare advantage hmo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 2425.05 2425.05 united health care medicare advantage ppo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 2425.05 2425.05 united health care medicare advantage pos ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 2425.05 2425.05 united health care medicare advantage epo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 2425.05 2425.05 united health care medicare advantage ppo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 2425.05 2425.05 united health care medicare advantage pos ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 2425.05 2425.05 united health care medicare advantage hmo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1952.13 1952.13 united health care medicare advantage hmo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1952.13 1952.13 united health care medicare advantage ppo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1952.13 1952.13 united health care medicare advantage pos furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1952.13 1952.13 united health care medicare advantage epo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1952.13 1952.13 united health care medicare advantage ppo furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1952.13 1952.13 united health care medicare advantage pos furosemide injection cpt J1940 5563.26 5563.26 934.71 934.71 10630.08 10630.08 8858.4 8858.4 E 1952.13 1952.13 united health care medicare advantage hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4547.22 4547.22 united health care medicare advantage hmo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4547.22 4547.22 united health care medicare advantage ppo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4547.22 4547.22 united health care medicare advantage pos ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4547.22 4547.22 united health care medicare advantage epo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4547.22 4547.22 united health care medicare advantage ppo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4547.22 4547.22 united health care medicare advantage pos ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 4547.22 4547.22 united health care medicare advantage hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage hmo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage pos Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage epo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage pos Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 47.76 47.76 united health care medicare advantage hmo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 331.51 331.51 united health care medicare advantage hmo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 331.51 331.51 united health care medicare advantage ppo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 331.51 331.51 united health care medicare advantage pos CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 331.51 331.51 united health care medicare advantage epo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 331.51 331.51 united health care medicare advantage ppo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 331.51 331.51 united health care medicare advantage pos CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 331.51 331.51 united health care medicare advantage hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1965.52 1965.52 united health care medicare advantage hmo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1965.52 1965.52 united health care medicare advantage ppo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1965.52 1965.52 united health care medicare advantage pos furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1965.52 1965.52 united health care medicare advantage epo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1965.52 1965.52 united health care medicare advantage ppo furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1965.52 1965.52 united health care medicare advantage pos furosemide injection cpt J1940 4187.14 4187.14 309.3 309.3 12590.1 12590.1 10491.75 10491.75 O 1965.52 1965.52 united health care medicare advantage hmo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 151.7 151.7 united health care medicare advantage hmo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 151.7 151.7 united health care medicare advantage ppo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 151.7 151.7 united health care medicare advantage pos "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 151.7 151.7 united health care medicare advantage epo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 151.7 151.7 united health care medicare advantage ppo "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 151.7 151.7 united health care medicare advantage pos "Removal of tissue from wounds per session, each additional 20 sq cm" cpt 97598 257.49 257.49 151.7 151.7 2237.82 2237.82 1864.85 1864.85 O 151.7 151.7 united health care medicare advantage hmo absorpt drg > 48 sq in w/o b cpt A6253 1346.02 1346.02 100.65 100.65 2537.39 2537.39 2114.49 2114.49 O 100.65 100.65 united health care medicare advantage hmo absorpt drg > 48 sq in w/o b cpt A6253 1346.02 1346.02 100.65 100.65 2537.39 2537.39 2114.49 2114.49 O 100.65 100.65 united health care medicare advantage ppo absorpt drg > 48 sq in w/o b cpt A6253 1346.02 1346.02 100.65 100.65 2537.39 2537.39 2114.49 2114.49 O 100.65 100.65 united health care medicare advantage pos absorpt drg > 48 sq in w/o b cpt A6253 1346.02 1346.02 100.65 100.65 2537.39 2537.39 2114.49 2114.49 O 100.65 100.65 united health care medicare advantage epo absorpt drg > 48 sq in w/o b cpt A6253 1346.02 1346.02 100.65 100.65 2537.39 2537.39 2114.49 2114.49 O 100.65 100.65 united health care medicare advantage ppo absorpt drg > 48 sq in w/o b cpt A6253 1346.02 1346.02 100.65 100.65 2537.39 2537.39 2114.49 2114.49 O 100.65 100.65 united health care medicare advantage pos absorpt drg > 48 sq in w/o b cpt A6253 1346.02 1346.02 100.65 100.65 2537.39 2537.39 2114.49 2114.49 O 100.65 100.65 united health care medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 2048.12 2048.12 united health care medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 2048.12 2048.12 united health care medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 2048.12 2048.12 united health care medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 2048.12 2048.12 united health care medicare advantage epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 2048.12 2048.12 united health care medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 2048.12 2048.12 united health care medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 7694.58 7694.58 1325.13 1325.13 16579.92 16579.92 13816.6 13816.6 E 2048.12 2048.12 united health care medicare advantage hmo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 united health care medicare advantage hmo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 united health care medicare advantage ppo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 united health care medicare advantage pos Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 united health care medicare advantage epo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 united health care medicare advantage ppo Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 united health care medicare advantage pos Repair of groin hernia patient age 5 years or older cpt 49505 2754.5 2754.5 2537.42 2537.42 19425.92 19425.92 16188.27 16188.27 O 2754.5 2754.5 united health care medicare advantage hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 3518.3 3518.3 united health care medicare advantage hmo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 3518.3 3518.3 united health care medicare advantage ppo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 3518.3 3518.3 united health care medicare advantage pos acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 3518.3 3518.3 united health care medicare advantage epo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 3518.3 3518.3 united health care medicare advantage ppo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 3518.3 3518.3 united health care medicare advantage pos acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 3518.3 3518.3 united health care medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 948.37 948.37 united health care medicare advantage hmo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 948.37 948.37 united health care medicare advantage ppo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 948.37 948.37 united health care medicare advantage pos Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 948.37 948.37 united health care medicare advantage epo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 948.37 948.37 united health care medicare advantage ppo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 948.37 948.37 united health care medicare advantage pos Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 948.37 948.37 united health care medicare advantage hmo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 508.17 508.17 united health care medicare advantage hmo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 508.17 508.17 united health care medicare advantage ppo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 508.17 508.17 united health care medicare advantage pos levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 508.17 508.17 united health care medicare advantage epo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 508.17 508.17 united health care medicare advantage ppo levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 508.17 508.17 united health care medicare advantage pos levetiracetam injection cpt J1953 3173.26 3173.26 180.31 180.31 4085.39 4085.39 3404.49 3404.49 E 508.17 508.17 united health care medicare advantage hmo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 united health care medicare advantage hmo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 united health care medicare advantage ppo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 united health care medicare advantage pos tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 united health care medicare advantage epo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 united health care medicare advantage ppo tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 united health care medicare advantage pos tc99m sestamibi cpt A9500 10082.72 10082.72 1489.46 1489.46 18292.38 18292.38 15243.65 15243.65 E 1965.52 1965.52 united health care medicare advantage hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 united health care medicare advantage hmo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 united health care medicare advantage ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 united health care medicare advantage pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 united health care medicare advantage epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 united health care medicare advantage ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 united health care medicare advantage pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 6.01 6.01 united health care medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 united health care medicare advantage hmo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 united health care medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 united health care medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 united health care medicare advantage epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 united health care medicare advantage ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 united health care medicare advantage pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 426.62 426.62 united health care medicare advantage hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 united health care medicare advantage hmo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 united health care medicare advantage ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 united health care medicare advantage pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 united health care medicare advantage epo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 united health care medicare advantage ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 united health care medicare advantage pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 united health care medicare advantage hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 united health care medicare advantage hmo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 united health care medicare advantage ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 united health care medicare advantage pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 united health care medicare advantage epo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 united health care medicare advantage ppo Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 united health care medicare advantage pos Natriuretic peptide (heart and blood vessel protein) level cpt 83880 89.87 89.87 23.26 23.26 140.29 140.29 116.91 116.91 O 39.26 39.26 united health care medicare advantage hmo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 2425.05 2425.05 united health care medicare advantage hmo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 2425.05 2425.05 united health care medicare advantage ppo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 2425.05 2425.05 united health care medicare advantage pos meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 2425.05 2425.05 united health care medicare advantage epo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 2425.05 2425.05 united health care medicare advantage ppo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 2425.05 2425.05 united health care medicare advantage pos meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 2425.05 2425.05 united health care medicare advantage hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 united health care medicare advantage hmo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 united health care medicare advantage ppo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 united health care medicare advantage pos Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 united health care medicare advantage epo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 united health care medicare advantage ppo Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 united health care medicare advantage pos Imaging of liver and bile duct system with use of drugs cpt 78227 1030.32 1030.32 345.06 345.06 1648.51 1648.51 1373.76 1373.76 O 418.12 418.12 united health care medicare advantage hmo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 united health care medicare advantage hmo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 united health care medicare advantage ppo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 united health care medicare advantage pos Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 united health care medicare advantage epo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 united health care medicare advantage ppo Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 united health care medicare advantage pos Transfusion of blood or blood products cpt 36430 3837.05 3837.05 1238.1 1238.1 9634.22 9634.22 8028.52 8028.52 E 1952.13 1952.13 united health care medicare advantage hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 11672.55 11672.55 united health care medicare advantage hmo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 11672.55 11672.55 united health care medicare advantage ppo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 11672.55 11672.55 united health care medicare advantage pos diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 11672.55 11672.55 united health care medicare advantage epo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 11672.55 11672.55 united health care medicare advantage ppo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 11672.55 11672.55 united health care medicare advantage pos diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 11672.55 11672.55 united health care medicare advantage hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 2006.82 2006.82 united health care medicare advantage hmo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 2006.82 2006.82 united health care medicare advantage ppo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 2006.82 2006.82 united health care medicare advantage pos hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 2006.82 2006.82 united health care medicare advantage epo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 2006.82 2006.82 united health care medicare advantage ppo hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 2006.82 2006.82 united health care medicare advantage pos hospital observation per hr cpt G0378 8278.58 8278.58 1934.02 1934.02 14212.01 14212.01 11843.34 11843.34 E 2006.82 2006.82 united health care medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 united health care medicare advantage hmo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 united health care medicare advantage ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 united health care medicare advantage pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 united health care medicare advantage epo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 united health care medicare advantage ppo Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 united health care medicare advantage pos Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging interpretation and supervision and injection cpt 93458 16100.16 16100.16 700.09 700.09 27567.08 27567.08 22972.57 22972.57 O 2524.71 2524.71 united health care medicare advantage hmo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 508.17 508.17 united health care medicare advantage hmo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 508.17 508.17 united health care medicare advantage ppo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 508.17 508.17 united health care medicare advantage pos lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 508.17 508.17 united health care medicare advantage epo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 508.17 508.17 united health care medicare advantage ppo lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 508.17 508.17 united health care medicare advantage pos lorazepam injection cpt J2060 3662.54 3662.54 465.08 465.08 6132.2 6132.2 5110.17 5110.17 E 508.17 508.17 united health care medicare advantage hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 united health care medicare advantage hmo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 united health care medicare advantage ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 united health care medicare advantage pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 united health care medicare advantage epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 united health care medicare advantage ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 united health care medicare advantage pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 9.71 9.71 united health care medicare advantage hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 1965.52 1965.52 united health care medicare advantage hmo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 1965.52 1965.52 united health care medicare advantage ppo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 1965.52 1965.52 united health care medicare advantage pos rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 1965.52 1965.52 united health care medicare advantage epo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 1965.52 1965.52 united health care medicare advantage ppo rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 1965.52 1965.52 united health care medicare advantage pos rbc leukocytes reduced cpt P9016 6865.24 6865.24 707.85 707.85 3894.85 3894.85 3245.71 3245.71 O 1965.52 1965.52 united health care medicare advantage hmo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5099.7 5099.7 united health care medicare advantage hmo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5099.7 5099.7 united health care medicare advantage ppo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5099.7 5099.7 united health care medicare advantage pos syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5099.7 5099.7 united health care medicare advantage epo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5099.7 5099.7 united health care medicare advantage ppo syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5099.7 5099.7 united health care medicare advantage pos syncope and collapse ms-drg 312 5784.83 5784.83 5099.7 5099.7 21273.84 21273.84 17728.2 17728.2 I 5099.7 5099.7 united health care medicare advantage hmo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 2425.05 2425.05 united health care medicare advantage hmo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 2425.05 2425.05 united health care medicare advantage ppo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 2425.05 2425.05 united health care medicare advantage pos lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 2425.05 2425.05 united health care medicare advantage epo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 2425.05 2425.05 united health care medicare advantage ppo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 2425.05 2425.05 united health care medicare advantage pos lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 2425.05 2425.05 united health care medicare advantage hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 united health care medicare advantage hmo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 united health care medicare advantage ppo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 united health care medicare advantage pos Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 united health care medicare advantage epo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 united health care medicare advantage ppo Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 united health care medicare advantage pos Repair of groin hernia using an endoscope cpt 49650 19046.96 19046.96 3914.78 3914.78 27702.36 27702.36 23085.3 23085.3 O 4282.09 4282.09 united health care medicare advantage hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10597.75 10597.75 united health care medicare advantage hmo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10597.75 10597.75 united health care medicare advantage ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10597.75 10597.75 united health care medicare advantage pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10597.75 10597.75 united health care medicare advantage epo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10597.75 10597.75 united health care medicare advantage ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10597.75 10597.75 united health care medicare advantage pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 10597.75 10597.75 united health care medicare advantage hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 214.42 214.42 united health care medicare advantage hmo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 214.42 214.42 united health care medicare advantage ppo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 214.42 214.42 united health care medicare advantage pos CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 214.42 214.42 united health care medicare advantage epo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 214.42 214.42 united health care medicare advantage ppo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 214.42 214.42 united health care medicare advantage pos CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 214.42 214.42 united health care medicare advantage hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 97.31 97.31 united health care medicare advantage hmo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 97.31 97.31 united health care medicare advantage ppo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 97.31 97.31 united health care medicare advantage pos CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 97.31 97.31 united health care medicare advantage epo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 97.31 97.31 united health care medicare advantage ppo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 97.31 97.31 united health care medicare advantage pos CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 97.31 97.31 united health care medicare advantage hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1134.65 1134.65 united health care medicare advantage hmo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1134.65 1134.65 united health care medicare advantage ppo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1134.65 1134.65 united health care medicare advantage pos normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1134.65 1134.65 united health care medicare advantage epo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1134.65 1134.65 united health care medicare advantage ppo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1134.65 1134.65 united health care medicare advantage pos normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1134.65 1134.65 united health care medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 united health care medicare advantage hmo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 united health care medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 united health care medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 united health care medicare advantage epo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 united health care medicare advantage ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 united health care medicare advantage pos Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 1965.52 1965.52 united health care medicare advantage hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 82.1 82.1 united health care medicare advantage hmo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 82.1 82.1 united health care medicare advantage ppo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 82.1 82.1 united health care medicare advantage pos Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 82.1 82.1 united health care medicare advantage epo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 82.1 82.1 united health care medicare advantage ppo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 82.1 82.1 united health care medicare advantage pos Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 82.1 82.1 united health care medicare advantage hmo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 united health care medicare advantage hmo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 united health care medicare advantage ppo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 united health care medicare advantage pos adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 united health care medicare advantage epo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 united health care medicare advantage ppo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 united health care medicare advantage pos adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 2425.05 2425.05 united health care medicare advantage hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6290.88 6290.88 united health care medicare advantage hmo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6290.88 6290.88 united health care medicare advantage ppo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6290.88 6290.88 united health care medicare advantage pos intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6290.88 6290.88 united health care medicare advantage epo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6290.88 6290.88 united health care medicare advantage ppo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6290.88 6290.88 united health care medicare advantage pos intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 6290.88 6290.88 united health care medicare advantage hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8625.11 8625.11 united health care medicare advantage hmo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8625.11 8625.11 united health care medicare advantage ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8625.11 8625.11 united health care medicare advantage pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8625.11 8625.11 united health care medicare advantage epo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8625.11 8625.11 united health care medicare advantage ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8625.11 8625.11 united health care medicare advantage pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 8625.11 8625.11 united health care medicare advantage hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 277.79 277.79 united health care medicare advantage hmo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 277.79 277.79 united health care medicare advantage ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 277.79 277.79 united health care medicare advantage pos Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 277.79 277.79 united health care medicare advantage epo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 277.79 277.79 united health care medicare advantage ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 277.79 277.79 united health care medicare advantage pos Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 277.79 277.79 united health care medicare advantage hmo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1952.13 1952.13 united health care medicare advantage hmo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1952.13 1952.13 united health care medicare advantage ppo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1952.13 1952.13 united health care medicare advantage pos normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1952.13 1952.13 united health care medicare advantage epo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1952.13 1952.13 united health care medicare advantage ppo normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1952.13 1952.13 united health care medicare advantage pos normal saline solution infus cpt J7040 13467.02 13467.02 607.33 607.33 6728.22 6728.22 5606.85 5606.85 E 1952.13 1952.13 united health care medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.65 20.65 united health care medicare advantage hmo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.65 20.65 united health care medicare advantage ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.65 20.65 united health care medicare advantage pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.65 20.65 united health care medicare advantage epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.65 20.65 united health care medicare advantage ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.65 20.65 united health care medicare advantage pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 20.65 20.65 united health care medicare advantage hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 13951.45 13951.45 united health care medicare advantage hmo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 13951.45 13951.45 united health care medicare advantage ppo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 13951.45 13951.45 united health care medicare advantage pos normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 13951.45 13951.45 united health care medicare advantage epo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 13951.45 13951.45 united health care medicare advantage ppo normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 13951.45 13951.45 united health care medicare advantage pos normal saline solution infus cpt J7030 14120.9 14120.9 1215.96 1215.96 7236.16 7236.16 6030.13 6030.13 O 13951.45 13951.45 united health care medicare advantage hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 united health care medicare advantage hmo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 united health care medicare advantage ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 united health care medicare advantage pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 united health care medicare advantage epo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 united health care medicare advantage ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 united health care medicare advantage pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 6.7 6.7 united health care medicare advantage hmo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 100.65 100.65 united health care medicare advantage hmo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 100.65 100.65 united health care medicare advantage ppo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 100.65 100.65 united health care medicare advantage pos hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 100.65 100.65 united health care medicare advantage epo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 100.65 100.65 united health care medicare advantage ppo hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 100.65 100.65 united health care medicare advantage pos hospital outpt clinic visit cpt G0463 343.78 343.78 100.65 100.65 200.98 200.98 167.48 167.48 O 100.65 100.65 united health care medicare advantage hmo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5287.75 5287.75 united health care medicare advantage hmo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5287.75 5287.75 united health care medicare advantage ppo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5287.75 5287.75 united health care medicare advantage pos multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5287.75 5287.75 united health care medicare advantage epo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5287.75 5287.75 united health care medicare advantage ppo multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5287.75 5287.75 united health care medicare advantage pos multiple sclerosis and cerebellar ataxia without cc/mcc ms-drg 60 12264.64 12264.64 4928.35 4928.35 22907.23 22907.23 19089.36 19089.36 I 5287.75 5287.75 united health care medicare advantage hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 united health care medicare advantage hmo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 united health care medicare advantage ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 united health care medicare advantage pos "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 united health care medicare advantage epo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 united health care medicare advantage ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 united health care medicare advantage pos "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 4.29 4.29 united health care medicare advantage hmo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 2034.24 2034.24 united health care medicare advantage hmo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 2034.24 2034.24 united health care medicare advantage ppo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 2034.24 2034.24 united health care medicare advantage pos normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 2034.24 2034.24 united health care medicare advantage epo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 2034.24 2034.24 united health care medicare advantage ppo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 2034.24 2034.24 united health care medicare advantage pos normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 2034.24 2034.24 united health care medicare advantage hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 1965.52 1965.52 united health care medicare advantage hmo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 1965.52 1965.52 united health care medicare advantage ppo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 1965.52 1965.52 united health care medicare advantage pos hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 1965.52 1965.52 united health care medicare advantage epo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 1965.52 1965.52 united health care medicare advantage ppo hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 1965.52 1965.52 united health care medicare advantage pos hospital observation per hr cpt G0378 6461 6461 1357.6 1357.6 26060.05 26060.05 21716.71 21716.71 O 1965.52 1965.52 united health care medicare advantage hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 united health care medicare advantage hmo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 united health care medicare advantage ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 united health care medicare advantage pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 united health care medicare advantage epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 united health care medicare advantage ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 united health care medicare advantage pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 20.05 20.05 united health care medicare advantage hmo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 2754.5 2754.5 united health care medicare advantage hmo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 2754.5 2754.5 united health care medicare advantage ppo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 2754.5 2754.5 united health care medicare advantage pos mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 2754.5 2754.5 united health care medicare advantage epo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 2754.5 2754.5 united health care medicare advantage ppo mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 2754.5 2754.5 united health care medicare advantage pos mesh (implantable) cpt C1781 7519.16 7519.16 2754.5 2754.5 27398.15 27398.15 22831.79 22831.79 O 2754.5 2754.5 united health care medicare advantage hmo Iron level cpt 83540 1862.13 1862.13 5.75 5.75 114.6 114.6 95.5 95.5 E 1862.13 1862.13 united health care medicare advantage hmo Iron level cpt 83540 1862.13 1862.13 5.75 5.75 114.6 114.6 95.5 95.5 E 1862.13 1862.13 united health care medicare advantage ppo Iron level cpt 83540 1862.13 1862.13 5.75 5.75 114.6 114.6 95.5 95.5 E 1862.13 1862.13 united health care medicare advantage pos Iron level cpt 83540 1862.13 1862.13 5.75 5.75 114.6 114.6 95.5 95.5 E 1862.13 1862.13 united health care medicare advantage epo Iron level cpt 83540 1862.13 1862.13 5.75 5.75 114.6 114.6 95.5 95.5 E 1862.13 1862.13 united health care medicare advantage ppo Iron level cpt 83540 1862.13 1862.13 5.75 5.75 114.6 114.6 95.5 95.5 E 1862.13 1862.13 united health care medicare advantage pos Iron level cpt 83540 1862.13 1862.13 5.75 5.75 114.6 114.6 95.5 95.5 E 1862.13 1862.13 united health care medicare advantage hmo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 13951.45 13951.45 united health care medicare advantage hmo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 13951.45 13951.45 united health care medicare advantage ppo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 13951.45 13951.45 united health care medicare advantage pos inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 13951.45 13951.45 united health care medicare advantage epo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 13951.45 13951.45 united health care medicare advantage ppo inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 13951.45 13951.45 united health care medicare advantage pos inj magnesium sulfate cpt J3475 13951.45 13951.45 832.09 832.09 17617.84 17617.84 14681.53 14681.53 O 13951.45 13951.45 united health care medicare advantage hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 united health care medicare advantage hmo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 united health care medicare advantage ppo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 united health care medicare advantage pos f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 united health care medicare advantage epo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 united health care medicare advantage ppo f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 united health care medicare advantage pos f18 fdg cpt A9552 6259.46 6259.46 1199.86 1199.86 9771.23 9771.23 8142.69 8142.69 O 1278.4 1278.4 united health care medicare advantage hmo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 9413.16 9413.16 united health care medicare advantage hmo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 9413.16 9413.16 united health care medicare advantage ppo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 9413.16 9413.16 united health care medicare advantage pos other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 9413.16 9413.16 united health care medicare advantage epo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 9413.16 9413.16 united health care medicare advantage ppo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 9413.16 9413.16 united health care medicare advantage pos other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 9413.16 9413.16 united health care medicare advantage hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.43 4.43 united health care medicare advantage hmo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.43 4.43 united health care medicare advantage ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.43 4.43 united health care medicare advantage pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.43 4.43 united health care medicare advantage epo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.43 4.43 united health care medicare advantage ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.43 4.43 united health care medicare advantage pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 4.43 4.43 united health care medicare advantage hmo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 united health care medicare advantage hmo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 united health care medicare advantage ppo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 united health care medicare advantage pos "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 united health care medicare advantage epo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 united health care medicare advantage ppo "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 united health care medicare advantage pos "Balloon dilation of esophagus, stomach and upper small bowel using a flexible endoscope" cpt 43249 4236.59 4236.59 1293.56 1293.56 5704.44 5704.44 4753.7 4753.7 O 1379.67 1379.67 united health care medicare advantage hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 16.99 16.99 united health care medicare advantage hmo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 16.99 16.99 united health care medicare advantage ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 16.99 16.99 united health care medicare advantage pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 16.99 16.99 united health care medicare advantage epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 16.99 16.99 united health care medicare advantage ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 16.99 16.99 united health care medicare advantage pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 16.99 16.99 united health care medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 united health care medicare advantage hmo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 united health care medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 united health care medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 united health care medicare advantage epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 united health care medicare advantage ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 united health care medicare advantage pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 7.77 7.77 united health care medicare advantage hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 united health care medicare advantage hmo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 united health care medicare advantage ppo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 united health care medicare advantage pos "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 united health care medicare advantage epo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 united health care medicare advantage ppo "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 united health care medicare advantage pos "Emergency department visit, problem with significant threat to life or function" cpt 99285 7986.58 7986.58 609.71 609.71 9248.9 9248.9 7707.42 7707.42 E 1952.13 1952.13 united health care medicare advantage hmo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 united health care medicare advantage hmo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 united health care medicare advantage ppo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 united health care medicare advantage pos rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 united health care medicare advantage epo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 united health care medicare advantage ppo rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 united health care medicare advantage pos rbc leukocytes reduced cpt P9016 3837.05 3837.05 936.47 936.47 8320.81 8320.81 6934.01 6934.01 E 1952.13 1952.13 united health care medicare advantage hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1965.52 1965.52 united health care medicare advantage hmo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1965.52 1965.52 united health care medicare advantage ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1965.52 1965.52 united health care medicare advantage pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1965.52 1965.52 united health care medicare advantage epo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1965.52 1965.52 united health care medicare advantage ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1965.52 1965.52 united health care medicare advantage pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 3792.31 3792.31 919.47 919.47 10709.24 10709.24 8924.37 8924.37 E 1965.52 1965.52 united health care medicare advantage hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 united health care medicare advantage hmo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 united health care medicare advantage ppo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 united health care medicare advantage pos "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 united health care medicare advantage epo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 united health care medicare advantage ppo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 united health care medicare advantage pos "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 18.39 18.39 united health care medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 2102.95 2102.95 united health care medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 2102.95 2102.95 united health care medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 2102.95 2102.95 united health care medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 2102.95 2102.95 united health care medicare advantage epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 2102.95 2102.95 united health care medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 2102.95 2102.95 united health care medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 2102.95 2102.95 united health care medicare advantage hmo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 1364 1364 united health care medicare advantage hmo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 1364 1364 united health care medicare advantage ppo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 1364 1364 united health care medicare advantage pos extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 1364 1364 united health care medicare advantage epo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 1364 1364 united health care medicare advantage ppo extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 1364 1364 united health care medicare advantage pos extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 981 29373.69 29373.69 1364 1364 90106.88 90106.88 75089.07 75089.07 I 1364 1364 united health care medicare advantage hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2109.65 2109.65 united health care medicare advantage hmo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2109.65 2109.65 united health care medicare advantage ppo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2109.65 2109.65 united health care medicare advantage pos "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2109.65 2109.65 united health care medicare advantage epo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2109.65 2109.65 united health care medicare advantage ppo "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2109.65 2109.65 united health care medicare advantage pos "Evaluation of occupational therapy established plan of care, typically 60 minutes" cpt 97167 2109.65 2109.65 1084.08 1084.08 16816.88 16816.88 14014.07 14014.07 E 2109.65 2109.65 united health care medicare advantage hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 united health care medicare advantage hmo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 united health care medicare advantage ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 united health care medicare advantage pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 united health care medicare advantage epo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 united health care medicare advantage ppo Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 united health care medicare advantage pos Urine microalbumin (protein) level cpt 82043 47.82 47.82 5.14 5.14 72.88 72.88 60.73 60.73 O 5.78 5.78 united health care medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4881.58 4881.58 united health care medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4881.58 4881.58 united health care medicare advantage ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4881.58 4881.58 united health care medicare advantage pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4881.58 4881.58 united health care medicare advantage epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4881.58 4881.58 united health care medicare advantage ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4881.58 4881.58 united health care medicare advantage pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 9805.54 9805.54 1660.16 1660.16 20760 20760 17300 17300 O 4881.58 4881.58 united health care medicare advantage hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 united health care medicare advantage hmo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 united health care medicare advantage ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 united health care medicare advantage pos Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 united health care medicare advantage epo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 united health care medicare advantage ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 united health care medicare advantage pos Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 6.47 6.47 united health care medicare advantage hmo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 13951.45 13951.45 united health care medicare advantage hmo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 13951.45 13951.45 united health care medicare advantage ppo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 13951.45 13951.45 united health care medicare advantage pos tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 13951.45 13951.45 united health care medicare advantage epo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 13951.45 13951.45 united health care medicare advantage ppo tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 13951.45 13951.45 united health care medicare advantage pos tirofiban hcl cpt J3246 14156.17 14156.17 8630.33 8630.33 79426.56 79426.56 66188.8 66188.8 O 13951.45 13951.45 united health care medicare advantage hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 3014.64 3014.64 united health care medicare advantage hmo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 3014.64 3014.64 united health care medicare advantage ppo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 3014.64 3014.64 united health care medicare advantage pos Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 3014.64 3014.64 united health care medicare advantage epo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 3014.64 3014.64 united health care medicare advantage ppo Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 3014.64 3014.64 united health care medicare advantage pos Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle cpt 96401 15419.2 15419.2 851.57 851.57 18354.96 18354.96 15295.8 15295.8 O 3014.64 3014.64 united health care medicare advantage hmo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 83.26 83.26 united health care medicare advantage hmo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 83.26 83.26 united health care medicare advantage ppo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 83.26 83.26 united health care medicare advantage pos Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 83.26 83.26 united health care medicare advantage epo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 83.26 83.26 united health care medicare advantage ppo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 83.26 83.26 united health care medicare advantage pos Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 83.26 83.26 united health care medicare advantage hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1965.52 1965.52 united health care medicare advantage hmo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1965.52 1965.52 united health care medicare advantage ppo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1965.52 1965.52 united health care medicare advantage pos Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1965.52 1965.52 united health care medicare advantage epo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1965.52 1965.52 united health care medicare advantage ppo Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1965.52 1965.52 united health care medicare advantage pos Transfusion of blood or blood products cpt 36430 6865.24 6865.24 663.49 663.49 3881.7 3881.7 3234.75 3234.75 O 1965.52 1965.52 united health care medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 829.53 829.53 united health care medicare advantage hmo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 829.53 829.53 united health care medicare advantage ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 829.53 829.53 united health care medicare advantage pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 829.53 829.53 united health care medicare advantage epo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 829.53 829.53 united health care medicare advantage ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 829.53 829.53 united health care medicare advantage pos "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 829.53 829.53 united health care medicare advantage hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 58.51 58.51 united health care medicare advantage hmo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 58.51 58.51 united health care medicare advantage ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 58.51 58.51 united health care medicare advantage pos "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 58.51 58.51 united health care medicare advantage epo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 58.51 58.51 united health care medicare advantage ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 58.51 58.51 united health care medicare advantage pos "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 58.51 58.51 united health care medicare advantage hmo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 151.7 151.7 united health care medicare advantage hmo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 151.7 151.7 united health care medicare advantage ppo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 151.7 151.7 united health care medicare advantage pos ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 151.7 151.7 united health care medicare advantage epo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 151.7 151.7 united health care medicare advantage ppo ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 151.7 151.7 united health care medicare advantage pos ambulatory surgical boot eac cpt L3260 572.85 572.85 102.7 102.7 1959.44 1959.44 1632.87 1632.87 O 151.7 151.7 united health care medicare advantage hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1965.52 1965.52 united health care medicare advantage hmo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1965.52 1965.52 united health care medicare advantage ppo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1965.52 1965.52 united health care medicare advantage pos "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1965.52 1965.52 united health care medicare advantage epo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1965.52 1965.52 united health care medicare advantage ppo "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1965.52 1965.52 united health care medicare advantage pos "Critical care delivery critically ill or injured patient, first 30-74 minutes" cpt 99291 5325.99 5325.99 787.11 787.11 9663.88 9663.88 8053.23 8053.23 O 1965.52 1965.52 united health care medicare advantage hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2754.5 2754.5 united health care medicare advantage hmo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2754.5 2754.5 united health care medicare advantage ppo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2754.5 2754.5 united health care medicare advantage pos cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2754.5 2754.5 united health care medicare advantage epo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2754.5 2754.5 united health care medicare advantage ppo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2754.5 2754.5 united health care medicare advantage pos cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 2754.5 2754.5 united health care medicare advantage hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 109.9 109.9 united health care medicare advantage hmo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 109.9 109.9 united health care medicare advantage ppo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 109.9 109.9 united health care medicare advantage pos Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 109.9 109.9 united health care medicare advantage epo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 109.9 109.9 united health care medicare advantage ppo Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 109.9 109.9 united health care medicare advantage pos Radiation therapy consultation per week cpt 77336 194.78 194.78 109.9 109.9 311.64 311.64 259.7 259.7 O 109.9 109.9 united health care medicare advantage hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2185.48 2185.48 united health care medicare advantage hmo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2185.48 2185.48 united health care medicare advantage ppo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2185.48 2185.48 united health care medicare advantage pos "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2185.48 2185.48 united health care medicare advantage epo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2185.48 2185.48 united health care medicare advantage ppo "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2185.48 2185.48 united health care medicare advantage pos "injection, fulvestrant" cpt J9395 10340.17 10340.17 1275.13 1275.13 9285.05 9285.05 7737.54 7737.54 O 2185.48 2185.48 united health care medicare advantage hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 4282.09 4282.09 united health care medicare advantage hmo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 4282.09 4282.09 united health care medicare advantage ppo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 4282.09 4282.09 united health care medicare advantage pos fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 4282.09 4282.09 united health care medicare advantage epo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 4282.09 4282.09 united health care medicare advantage ppo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 4282.09 4282.09 united health care medicare advantage pos fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 4282.09 4282.09 united health care medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 2102.95 2102.95 united health care medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 2102.95 2102.95 united health care medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 2102.95 2102.95 united health care medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 2102.95 2102.95 united health care medicare advantage epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 2102.95 2102.95 united health care medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 2102.95 2102.95 united health care medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 2102.95 2102.95 united health care medicare advantage hmo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2102.95 2102.95 united health care medicare advantage hmo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2102.95 2102.95 united health care medicare advantage ppo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2102.95 2102.95 united health care medicare advantage pos ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2102.95 2102.95 united health care medicare advantage epo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2102.95 2102.95 united health care medicare advantage ppo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2102.95 2102.95 united health care medicare advantage pos ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 2102.95 2102.95 united health care medicare advantage hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 united health care medicare advantage hmo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 united health care medicare advantage ppo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 united health care medicare advantage pos Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 united health care medicare advantage epo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 united health care medicare advantage ppo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 united health care medicare advantage pos Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 8.17 8.17 united health care medicare advantage hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 98.3 98.3 united health care medicare advantage hmo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 98.3 98.3 united health care medicare advantage ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 98.3 98.3 united health care medicare advantage pos "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 98.3 98.3 united health care medicare advantage epo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 98.3 98.3 united health care medicare advantage ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 98.3 98.3 united health care medicare advantage pos "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 98.3 98.3 united health care medicare advantage hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 750.44 750.44 united health care medicare advantage hmo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 750.44 750.44 united health care medicare advantage ppo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 750.44 750.44 united health care medicare advantage pos ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 750.44 750.44 united health care medicare advantage epo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 750.44 750.44 united health care medicare advantage ppo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 750.44 750.44 united health care medicare advantage pos ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 750.44 750.44 united health care medicare advantage hmo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 829.53 829.53 united health care medicare advantage hmo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 829.53 829.53 united health care medicare advantage ppo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 829.53 829.53 united health care medicare advantage pos fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 829.53 829.53 united health care medicare advantage epo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 829.53 829.53 united health care medicare advantage ppo fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 829.53 829.53 united health care medicare advantage pos fentanyl citrate injection cpt J3010 21270.9 21270.9 669.04 669.04 8781.7 8781.7 7318.08 7318.08 E 829.53 829.53 united health care medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1965.52 1965.52 united health care medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1965.52 1965.52 united health care medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1965.52 1965.52 united health care medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1965.52 1965.52 united health care medicare advantage epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1965.52 1965.52 united health care medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1965.52 1965.52 united health care medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 26702.62 26702.62 906.43 906.43 6417.79 6417.79 5348.16 5348.16 O 1965.52 1965.52 united health care medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 800.18 800.18 united health care medicare advantage hmo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 800.18 800.18 united health care medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 800.18 800.18 united health care medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 800.18 800.18 united health care medicare advantage epo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 800.18 800.18 united health care medicare advantage ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 800.18 800.18 united health care medicare advantage pos "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 800.18 800.18 united health care medicare advantage hmo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14036.18 14036.18 united health care medicare advantage hmo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14036.18 14036.18 united health care medicare advantage ppo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14036.18 14036.18 united health care medicare advantage pos "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14036.18 14036.18 united health care medicare advantage epo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14036.18 14036.18 united health care medicare advantage ppo "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14036.18 14036.18 united health care medicare advantage pos "catheter, guiding" cpt C1887 14156.17 14156.17 2489.54 2489.54 59222.6 59222.6 49352.17 49352.17 O 14036.18 14036.18 united health care medicare advantage hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12634.22 12634.22 united health care medicare advantage hmo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12634.22 12634.22 united health care medicare advantage ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12634.22 12634.22 united health care medicare advantage pos percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12634.22 12634.22 united health care medicare advantage epo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12634.22 12634.22 united health care medicare advantage ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12634.22 12634.22 united health care medicare advantage pos percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 12634.22 12634.22 united health care medicare advantage hmo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 united health care medicare advantage hmo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 united health care medicare advantage ppo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 united health care medicare advantage pos Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 united health care medicare advantage epo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 united health care medicare advantage ppo Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 united health care medicare advantage pos Vancomycin (antibiotic) level cpt 80202 36.28 36.28 12.04 12.04 89.04 89.04 74.2 74.2 O 13.54 13.54 united health care medicare advantage hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 united health care medicare advantage hmo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 united health care medicare advantage ppo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 united health care medicare advantage pos "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 united health care medicare advantage epo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 united health care medicare advantage ppo "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 united health care medicare advantage pos "Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older" cpt 36561 12335.28 12335.28 2329.97 2329.97 18210.46 18210.46 15175.38 15175.38 O 2455.02 2455.02 united health care medicare advantage hmo ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 united health care medicare advantage hmo ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 united health care medicare advantage ppo ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 united health care medicare advantage pos ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 united health care medicare advantage epo ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 united health care medicare advantage ppo ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 united health care medicare advantage pos ciprofloxacin iv cpt J0744 1952.13 1952.13 1158.82 1158.82 14026.28 14026.28 11688.57 11688.57 E 1952.13 1952.13 united health care medicare advantage hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 151.7 151.7 united health care medicare advantage hmo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 151.7 151.7 united health care medicare advantage ppo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 151.7 151.7 united health care medicare advantage pos "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 151.7 151.7 united health care medicare advantage epo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 151.7 151.7 united health care medicare advantage ppo "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 151.7 151.7 united health care medicare advantage pos "Removal of tissue from wounds per session, first 20 sq cms or less" cpt 97597 964.3 964.3 151.7 151.7 1106.5 1106.5 922.08 922.08 O 151.7 151.7 united health care medicare advantage hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 united health care medicare advantage hmo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 united health care medicare advantage ppo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 united health care medicare advantage pos "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 united health care medicare advantage epo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 united health care medicare advantage ppo "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 united health care medicare advantage pos "cath, bal dil, non-vascular" cpt C1726 3539.01 3539.01 1283.27 1283.27 5848.52 5848.52 4873.77 4873.77 O 1379.67 1379.67 united health care medicare advantage hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 united health care medicare advantage hmo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 united health care medicare advantage ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 united health care medicare advantage pos CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 united health care medicare advantage epo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 united health care medicare advantage ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 united health care medicare advantage pos CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 161.43 161.43 united health care medicare advantage hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage hmo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 20.05 20.05 united health care medicare advantage hmo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 united health care medicare advantage hmo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 united health care medicare advantage ppo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 united health care medicare advantage pos "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 united health care medicare advantage epo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 united health care medicare advantage ppo "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 united health care medicare advantage pos "port, indwelling, imp" cpt C1788 4400.88 4400.88 2275.09 2275.09 18357.68 18357.68 15298.07 15298.07 O 2455.02 2455.02 united health care medicare advantage hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 69.29 69.29 united health care medicare advantage hmo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 69.29 69.29 united health care medicare advantage ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 69.29 69.29 united health care medicare advantage pos "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 69.29 69.29 united health care medicare advantage epo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 69.29 69.29 united health care medicare advantage ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 69.29 69.29 united health care medicare advantage pos "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 69.29 69.29 united health care medicare advantage hmo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 750.44 750.44 united health care medicare advantage hmo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 750.44 750.44 united health care medicare advantage ppo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 750.44 750.44 united health care medicare advantage pos als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 750.44 750.44 united health care medicare advantage epo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 750.44 750.44 united health care medicare advantage ppo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 750.44 750.44 united health care medicare advantage pos als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 750.44 750.44 united health care medicare advantage hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 13951.45 13951.45 united health care medicare advantage hmo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 13951.45 13951.45 united health care medicare advantage ppo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 13951.45 13951.45 united health care medicare advantage pos guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 13951.45 13951.45 united health care medicare advantage epo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 13951.45 13951.45 united health care medicare advantage ppo guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 13951.45 13951.45 united health care medicare advantage pos guide wire cpt C1769 16039.46 16039.46 2524.71 2524.71 29114.52 29114.52 24262.1 24262.1 O 13951.45 13951.45 united health care medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 united health care medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 united health care medicare advantage ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 united health care medicare advantage pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 united health care medicare advantage epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 united health care medicare advantage ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 united health care medicare advantage pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 3844.63 3844.63 412.37 412.37 3941.83 3941.83 3284.86 3284.86 O 926.57 926.57 united health care medicare advantage hmo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1965.52 1965.52 united health care medicare advantage hmo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1965.52 1965.52 united health care medicare advantage ppo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1965.52 1965.52 united health care medicare advantage pos prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1965.52 1965.52 united health care medicare advantage epo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1965.52 1965.52 united health care medicare advantage ppo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1965.52 1965.52 united health care medicare advantage pos prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 1965.52 1965.52 united health care medicare advantage hmo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 11977.95 11977.95 united health care medicare advantage hmo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 11977.95 11977.95 united health care medicare advantage ppo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 11977.95 11977.95 united health care medicare advantage pos permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 11977.95 11977.95 united health care medicare advantage epo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 11977.95 11977.95 united health care medicare advantage ppo permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 11977.95 11977.95 united health care medicare advantage pos permanent cardiac pacemaker implant with cc ms-drg 243 20821.91 20821.91 11977.95 11977.95 67115.8 67115.8 55929.83 55929.83 I 11977.95 11977.95 united health care medicare advantage hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 950.89 950.89 united health care medicare advantage hmo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 950.89 950.89 united health care medicare advantage ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 950.89 950.89 united health care medicare advantage pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 950.89 950.89 united health care medicare advantage epo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 950.89 950.89 united health care medicare advantage ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 950.89 950.89 united health care medicare advantage pos "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 950.89 950.89 united health care medicare advantage hmo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14036.18 14036.18 united health care medicare advantage hmo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14036.18 14036.18 united health care medicare advantage ppo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14036.18 14036.18 united health care medicare advantage pos "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14036.18 14036.18 united health care medicare advantage epo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14036.18 14036.18 united health care medicare advantage ppo "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14036.18 14036.18 united health care medicare advantage pos "cath, translumin non-laser" cpt C1725 14120.9 14120.9 8127.49 8127.49 59442.06 59442.06 49535.05 49535.05 O 14036.18 14036.18 united health care medicare advantage hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10161.85 10161.85 united health care medicare advantage hmo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10161.85 10161.85 united health care medicare advantage ppo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10161.85 10161.85 united health care medicare advantage pos inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10161.85 10161.85 united health care medicare advantage epo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10161.85 10161.85 united health care medicare advantage ppo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10161.85 10161.85 united health care medicare advantage pos inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10161.85 10161.85 united health care medicare advantage hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 united health care medicare advantage hmo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 united health care medicare advantage ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 united health care medicare advantage pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 united health care medicare advantage epo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 united health care medicare advantage ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 united health care medicare advantage pos CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 338.27 338.27 united health care medicare advantage hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 united health care medicare advantage hmo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 united health care medicare advantage ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 united health care medicare advantage pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 united health care medicare advantage epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 united health care medicare advantage ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 united health care medicare advantage pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 13.39 13.39 united health care medicare advantage hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1128.66 1128.66 united health care medicare advantage hmo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1128.66 1128.66 united health care medicare advantage ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1128.66 1128.66 united health care medicare advantage pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1128.66 1128.66 united health care medicare advantage epo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1128.66 1128.66 united health care medicare advantage ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1128.66 1128.66 united health care medicare advantage pos regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1128.66 1128.66 united health care medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 2102.95 2102.95 united health care medicare advantage hmo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 2102.95 2102.95 united health care medicare advantage ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 2102.95 2102.95 united health care medicare advantage pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 2102.95 2102.95 united health care medicare advantage epo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 2102.95 2102.95 united health care medicare advantage ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 2102.95 2102.95 united health care medicare advantage pos "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 2102.95 2102.95 united health care medicare advantage hmo "epoetin alfa, non-esrd" cpt J0885 356.73 356.73 346.53 346.53 2339.21 2339.21 1949.34 1949.34 O 346.53 346.53 united health care medicare advantage hmo "epoetin alfa, non-esrd" cpt J0885 356.73 356.73 346.53 346.53 2339.21 2339.21 1949.34 1949.34 O 346.53 346.53 united health care medicare advantage ppo "epoetin alfa, non-esrd" cpt J0885 356.73 356.73 346.53 346.53 2339.21 2339.21 1949.34 1949.34 O 346.53 346.53 united health care medicare advantage pos "epoetin alfa, non-esrd" cpt J0885 356.73 356.73 346.53 346.53 2339.21 2339.21 1949.34 1949.34 O 346.53 346.53 united health care medicare advantage epo "epoetin alfa, non-esrd" cpt J0885 356.73 356.73 346.53 346.53 2339.21 2339.21 1949.34 1949.34 O 346.53 346.53 united health care medicare advantage ppo "epoetin alfa, non-esrd" cpt J0885 356.73 356.73 346.53 346.53 2339.21 2339.21 1949.34 1949.34 O 346.53 346.53 united health care medicare advantage pos "epoetin alfa, non-esrd" cpt J0885 356.73 356.73 346.53 346.53 2339.21 2339.21 1949.34 1949.34 O 346.53 346.53 united health care medicare advantage hmo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11724.47 11724.47 united health care medicare advantage hmo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11724.47 11724.47 united health care medicare advantage ppo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11724.47 11724.47 united health care medicare advantage pos hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11724.47 11724.47 united health care medicare advantage epo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11724.47 11724.47 united health care medicare advantage ppo hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11724.47 11724.47 united health care medicare advantage pos hip and femur procedures except major joint with cc ms-drg 481 22569.55 22569.55 11724.47 11724.47 73732.43 73732.43 61443.69 61443.69 I 11724.47 11724.47 united health care medicare advantage hmo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11531.6 11531.6 united health care medicare advantage hmo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11531.6 11531.6 united health care medicare advantage ppo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11531.6 11531.6 united health care medicare advantage pos intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11531.6 11531.6 united health care medicare advantage epo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11531.6 11531.6 united health care medicare advantage ppo intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11531.6 11531.6 united health care medicare advantage pos intracranial hemorrhage or cerebral infarction with mcc ms-drg 64 16230.79 16230.79 11088.29 11088.29 48903.64 48903.64 40753.03 40753.03 I 11531.6 11531.6 united health care medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.33 51.33 united health care medicare advantage hmo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.33 51.33 united health care medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.33 51.33 united health care medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.33 51.33 united health care medicare advantage epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.33 51.33 united health care medicare advantage ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.33 51.33 united health care medicare advantage pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.33 51.33 united health care medicare advantage hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1247.63 1247.63 united health care medicare advantage hmo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1247.63 1247.63 united health care medicare advantage ppo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1247.63 1247.63 united health care medicare advantage pos denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1247.63 1247.63 united health care medicare advantage epo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1247.63 1247.63 united health care medicare advantage ppo denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1247.63 1247.63 united health care medicare advantage pos denosumab injection cpt J0897 5612.54 5612.54 926.57 926.57 4592.54 4592.54 3827.12 3827.12 O 1247.63 1247.63 united health care medicare advantage hmo amputation for circulatory system disorders except upper limb and toe with cc ms-drg 240 16419.17 16419.17 11166.18 11166.18 56139.05 56139.05 46782.54 46782.54 I 16419.17 16419.17 united health care medicare advantage hmo amputation for circulatory system disorders except upper limb and toe with cc ms-drg 240 16419.17 16419.17 11166.18 11166.18 56139.05 56139.05 46782.54 46782.54 I 16419.17 16419.17 united health care medicare advantage ppo amputation for circulatory system disorders except upper limb and toe with cc ms-drg 240 16419.17 16419.17 11166.18 11166.18 56139.05 56139.05 46782.54 46782.54 I 16419.17 16419.17 united health care medicare advantage pos amputation for circulatory system disorders except upper limb and toe with cc ms-drg 240 16419.17 16419.17 11166.18 11166.18 56139.05 56139.05 46782.54 46782.54 I 16419.17 16419.17 united health care medicare advantage epo amputation for circulatory system disorders except upper limb and toe with cc ms-drg 240 16419.17 16419.17 11166.18 11166.18 56139.05 56139.05 46782.54 46782.54 I 16419.17 16419.17 united health care medicare advantage ppo amputation for circulatory system disorders except upper limb and toe with cc ms-drg 240 16419.17 16419.17 11166.18 11166.18 56139.05 56139.05 46782.54 46782.54 I 16419.17 16419.17 united health care medicare advantage pos amputation for circulatory system disorders except upper limb and toe with cc ms-drg 240 16419.17 16419.17 11166.18 11166.18 56139.05 56139.05 46782.54 46782.54 I 16419.17 16419.17 united health care medicare advantage hmo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 21.14 21.14 veterans affairs veterans affairs plan "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 21.14 21.14 veterans affairs ppo Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 2.86 2.86 veterans affairs veterans affairs plan Special Gram or Giemsa stain for microorganism cpt 87205 58.99 58.99 2.86 2.86 94.38 94.38 78.65 78.65 O 2.86 2.86 veterans affairs ppo other kidney and urinary tract diagnoses with cc ms-drg 699 7639.53 7639.53 4542.34 4542.34 24963.2 24963.2 20802.67 20802.67 I 4564.9 4564.9 veterans affairs veterans affairs plan other kidney and urinary tract diagnoses with cc ms-drg 699 7639.53 7639.53 4542.34 4542.34 24963.2 24963.2 20802.67 20802.67 I 4564.9 4564.9 veterans affairs ppo Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 6.95 6.95 veterans affairs veterans affairs plan Pancreatic elastase (enzyme) measurement cpt 82656 159.29 159.29 6.95 6.95 254.86 254.86 212.38 212.38 O 6.95 6.95 veterans affairs ppo Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 84.05 84.05 veterans affairs veterans affairs plan Irrigation of implanted venous access drug delivery device cpt 96523 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 84.05 84.05 veterans affairs ppo Special Gram or Giemsa stain for microorganism cpt 87205 82.58 82.58 3.8 3.8 94.38 94.38 78.65 78.65 E 82.58 82.58 veterans affairs veterans affairs plan Special Gram or Giemsa stain for microorganism cpt 87205 82.58 82.58 3.8 3.8 94.38 94.38 78.65 78.65 E 82.58 82.58 veterans affairs ppo "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 5.5 5.5 veterans affairs veterans affairs plan "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" cpt 87186 32.04 32.04 5.5 5.5 51.25 51.25 42.71 42.71 O 5.5 5.5 veterans affairs ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 79.61 79.61 veterans affairs veterans affairs plan Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 79.61 79.61 veterans affairs ppo Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 5.6 5.6 veterans affairs veterans affairs plan Gammaglobulin (immune system protein) measurement cpt 82784 46.91 46.91 5.6 5.6 75.05 75.05 62.54 62.54 O 5.6 5.6 veterans affairs ppo CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 125.7 125.7 veterans affairs veterans affairs plan CT scan of blood vessels in chest with contrast cpt 71275 1225.57 1225.57 125.7 125.7 1913.09 1913.09 1594.24 1594.24 E 125.7 125.7 veterans affairs ppo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 7.28 7.28 veterans affairs veterans affairs plan Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 7.28 7.28 veterans affairs ppo "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 688.83 688.83 veterans affairs veterans affairs plan "Emergency department visit, problem of high severity" cpt 99284 3567.22 3567.22 306.66 306.66 5029.38 5029.38 4191.15 4191.15 E 688.83 688.83 veterans affairs ppo General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 187.99 187.99 veterans affairs veterans affairs plan General revCode 250 2110.35 2110.35 187.99 187.99 5478.17 5478.17 4565.14 4565.14 E 187.99 187.99 veterans affairs ppo "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 2796.08 2796.08 veterans affairs veterans affairs plan "mri w/o fol w/cont, breast," cpt C8908 2796.08 2796.08 332.86 332.86 3655.21 3655.21 3046.01 3046.01 O 2796.08 2796.08 veterans affairs ppo gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 5478.66 5478.66 veterans affairs veterans affairs plan gastrointestinal hemorrhage with cc ms-drg 378 8605.42 8605.42 4373.52 4373.52 27388.28 27388.28 22823.57 22823.57 I 5478.66 5478.66 veterans affairs ppo Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 5.36 5.36 veterans affairs veterans affairs plan Smear for parasites cpt 87177 83.48 83.48 5.36 5.36 133.56 133.56 111.3 111.3 O 5.36 5.36 veterans affairs ppo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 11.16 11.16 veterans affairs veterans affairs plan "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 11.16 11.16 veterans affairs ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 2.87 2.87 veterans affairs veterans affairs plan "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 2.87 2.87 veterans affairs ppo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 5489.29 5489.29 veterans affairs veterans affairs plan General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 5489.29 5489.29 veterans affairs ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 127.89 127.89 veterans affairs veterans affairs plan MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 127.89 127.89 veterans affairs ppo Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 301.93 301.93 veterans affairs veterans affairs plan Insertion of needle into vein for collection of blood sample cpt 36415 8278.58 8278.58 301.93 301.93 7432.02 7432.02 6193.35 6193.35 E 301.93 301.93 veterans affairs ppo IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 5489.29 5489.29 veterans affairs veterans affairs plan IVsolutions revCode 258 11376.64 11376.64 1139.9 1139.9 18202.62 18202.62 15168.85 15168.85 O 5489.29 5489.29 veterans affairs ppo "infections, female reproductive system without cc/mcc" ms-drg 759 4954.74 4954.74 2807.47 2807.47 20152.96 20152.96 16794.13 16794.13 I 4954.74 4954.74 veterans affairs veterans affairs plan "infections, female reproductive system without cc/mcc" ms-drg 759 4954.74 4954.74 2807.47 2807.47 20152.96 20152.96 16794.13 16794.13 I 4954.74 4954.74 veterans affairs ppo "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 19.83 19.83 veterans affairs veterans affairs plan "X-ray of elbow, minimum of 3 views" cpt 73080 178.54 178.54 18.16 18.16 318 318 265 265 O 19.83 19.83 veterans affairs ppo "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 8.2 8.2 veterans affairs veterans affairs plan "Nephelometry, test method using light" cpt 83883 27.32 27.32 8.2 8.2 200.98 200.98 167.48 167.48 O 8.2 8.2 veterans affairs ppo "ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with mcc" ms-drg 61 40043.51 40043.51 11478.18 11478.18 64676.57 64676.57 53897.14 53897.14 I 11478.18 11478.18 veterans affairs veterans affairs plan "ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with mcc" ms-drg 61 40043.51 40043.51 11478.18 11478.18 64676.57 64676.57 53897.14 53897.14 I 11478.18 11478.18 veterans affairs ppo General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 563.29 563.29 veterans affairs veterans affairs plan General revCode 270 7240.33 7240.33 563.29 563.29 7424.89 7424.89 6187.41 6187.41 E 563.29 563.29 veterans affairs ppo Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 6403.21 6403.21 veterans affairs veterans affairs plan Removal of skin and bone first 20 sq cm or less cpt 11044 6403.21 6403.21 1171.1 1171.1 4542.24 4542.24 3785.2 3785.2 O 6403.21 6403.21 veterans affairs ppo postpartum and post abortion diagnoses with o.r. procedures ms-drg 769 6011.29 6011.29 4613.41 4613.41 37023.35 37023.35 30852.79 30852.79 I 6011.29 6011.29 veterans affairs veterans affairs plan postpartum and post abortion diagnoses with o.r. procedures ms-drg 769 6011.29 6011.29 4613.41 4613.41 37023.35 37023.35 30852.79 30852.79 I 6011.29 6011.29 veterans affairs ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 211.67 211.67 veterans affairs veterans affairs plan CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 O 211.67 211.67 veterans affairs ppo General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 1367.16 1367.16 veterans affairs veterans affairs plan General revCode 270 3909.17 3909.17 278.52 278.52 8905.74 8905.74 7421.45 7421.45 O 1367.16 1367.16 veterans affairs ppo colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1192.31 1192.31 veterans affairs veterans affairs plan colon ca scrn not hi rsk ind cpt G0121 2133.45 2133.45 618.13 618.13 3570.85 3570.85 2975.71 2975.71 O 1192.31 1192.31 veterans affairs ppo complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 7590.35 7590.35 veterans affairs veterans affairs plan complications of treatment with mcc ms-drg 919 11802.59 11802.59 7590.35 7590.35 35571.22 35571.22 29642.68 29642.68 I 7590.35 7590.35 veterans affairs ppo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 1628.83 1628.83 veterans affairs veterans affairs plan General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 1628.83 1628.83 veterans affairs ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 3.46 3.46 veterans affairs veterans affairs plan "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 3.46 3.46 veterans affairs ppo cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 5353.39 5353.39 veterans affairs veterans affairs plan cesarean section with sterilization with cc ms-drg 784 23094.84 23094.84 3311.09 3311.09 26725.74 26725.74 22271.45 22271.45 I 5353.39 5353.39 veterans affairs ppo CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 224.23 224.23 veterans affairs veterans affairs plan CT scan of abdomen and pelvis with contrast cpt 74177 2285.63 2285.63 198.18 198.18 3657 3657 3047.5 3047.5 E 224.23 224.23 veterans affairs ppo "X-ray of shoulder, 1 view" cpt 73020 203.52 203.52 13.25 13.25 244.22 244.22 203.52 203.52 O 203.52 203.52 veterans affairs veterans affairs plan "X-ray of shoulder, 1 view" cpt 73020 203.52 203.52 13.25 13.25 244.22 244.22 203.52 203.52 O 203.52 203.52 veterans affairs ppo normal newborn ms-drg 795 2082.25 2082.25 707.81 707.81 4256.4 4256.4 3547 3547 I 817.8 817.8 veterans affairs veterans affairs plan normal newborn ms-drg 795 2082.25 2082.25 707.81 707.81 4256.4 4256.4 3547 3547 I 817.8 817.8 veterans affairs ppo General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 9907.54 9907.54 veterans affairs veterans affairs plan General revCode 370 9907.54 9907.54 2076.66 2076.66 28909.84 28909.84 24091.53 24091.53 O 9907.54 9907.54 veterans affairs ppo joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 16572.45 16572.45 veterans affairs veterans affairs plan joint device (implantable) cpt C1776 16572.45 16572.45 4942.26 4942.26 40335.2 40335.2 33612.67 33612.67 O 16572.45 16572.45 veterans affairs ppo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 148.72 148.72 veterans affairs veterans affairs plan MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 148.72 148.72 veterans affairs ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 4.86 4.86 veterans affairs veterans affairs plan "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 4.86 4.86 veterans affairs ppo "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 114.84 114.84 veterans affairs veterans affairs plan "Bacterial colony count, urine" cpt 87086 160.59 160.59 7.18 7.18 256.94 256.94 214.12 214.12 E 114.84 114.84 veterans affairs ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 50.56 50.56 veterans affairs veterans affairs plan "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 50.56 50.56 veterans affairs ppo acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 11420.91 11420.91 veterans affairs veterans affairs plan acetaminophen injection cpt J0131 11420.91 11420.91 2274.34 2274.34 24287.22 24287.22 20239.35 20239.35 O 11420.91 11420.91 veterans affairs ppo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1628.83 1628.83 veterans affairs veterans affairs plan General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1628.83 1628.83 veterans affairs ppo Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 5.14 5.14 veterans affairs veterans affairs plan Bacterial culture for aerobic isolates cpt 87077 35.46 35.46 5.14 5.14 56.72 56.72 47.27 47.27 O 5.14 5.14 veterans affairs ppo Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 9907.54 9907.54 veterans affairs veterans affairs plan Partial removal of collar bone at shoulder using an endoscope cpt 29824 9907.54 9907.54 5299.29 5299.29 29878.18 29878.18 24898.48 24898.48 O 9907.54 9907.54 veterans affairs ppo Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 9907.54 9907.54 veterans affairs veterans affairs plan Extensive removal of shoulder joint tissue using an endoscope cpt 29823 9907.54 9907.54 2425.05 2425.05 28656.25 28656.25 23880.21 23880.21 O 9907.54 9907.54 veterans affairs ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 146.62 146.62 veterans affairs veterans affairs plan MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 146.62 146.62 veterans affairs ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 4.04 4.04 veterans affairs veterans affairs plan Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 4.04 4.04 veterans affairs ppo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 127.89 127.89 veterans affairs veterans affairs plan MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 127.89 127.89 veterans affairs ppo "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 2.61 2.61 veterans affairs veterans affairs plan "Blood test, clotting time" cpt 85610 50.5 50.5 2.61 2.61 76.96 76.96 64.13 64.13 E 2.61 2.61 veterans affairs ppo "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 6.34 6.34 veterans affairs veterans affairs plan "Bacterial culture, any source, except blood, anaerobic" cpt 87075 57.31 57.31 6.34 6.34 91.7 91.7 76.42 76.42 O 6.34 6.34 veterans affairs ppo CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 119.9 119.9 veterans affairs veterans affairs plan CT scan chest with contrast cpt 71260 1195.68 1195.68 119.9 119.9 1913.09 1913.09 1594.24 1594.24 O 119.9 119.9 veterans affairs ppo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 7339.89 7339.89 veterans affairs veterans affairs plan intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 7339.89 7339.89 veterans affairs ppo General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 15628.14 15628.14 veterans affairs veterans affairs plan General revCode 710 16160.85 16160.85 2524.71 2524.71 40897.36 40897.36 34081.13 34081.13 O 15628.14 15628.14 veterans affairs ppo "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 32.64 32.64 veterans affairs veterans affairs plan "Blood test, clotting time" cpt 85610 32.64 32.64 3.82 3.82 39.17 39.17 32.64 32.64 O 32.64 32.64 veterans affairs ppo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 5.77 5.77 veterans affairs veterans affairs plan "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 5.77 5.77 veterans affairs ppo "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 311.64 311.64 138.5 138.5 1779.53 1779.53 1482.94 1482.94 E 138.5 138.5 veterans affairs veterans affairs plan "Application of non-moveable, short arm splint (forearm to hand)" cpt 29125 311.64 311.64 138.5 138.5 1779.53 1779.53 1482.94 1482.94 E 138.5 138.5 veterans affairs ppo "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 268.55 268.55 veterans affairs veterans affairs plan "Emergency department visit, moderately severe problem" cpt 99283 917.66 917.66 194.68 194.68 1178.7 1178.7 982.25 982.25 E 268.55 268.55 veterans affairs ppo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 197.1 197.1 7.67 7.67 193.44 193.44 161.2 161.2 E 197.1 197.1 veterans affairs veterans affairs plan "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 197.1 197.1 7.67 7.67 193.44 193.44 161.2 161.2 E 197.1 197.1 veterans affairs ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 29.09 29.09 veterans affairs veterans affairs plan "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 29.09 29.09 veterans affairs ppo ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 549.41 549.41 veterans affairs veterans affairs plan ground mileage cpt A0425 2862 2862 352.05 352.05 1347.05 1347.05 1122.54 1122.54 O 549.41 549.41 veterans affairs ppo Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 62.45 62.45 veterans affairs veterans affairs plan Magnesium level cpt 83735 90.32 90.32 5.96 5.96 137.63 137.63 114.69 114.69 E 62.45 62.45 veterans affairs ppo Spinal tap with drainage of spinal fluid cpt 62272 6841.37 6841.37 1003.2 1003.2 4703.68 4703.68 3919.73 3919.73 E 6841.37 6841.37 veterans affairs veterans affairs plan Spinal tap with drainage of spinal fluid cpt 62272 6841.37 6841.37 1003.2 1003.2 4703.68 4703.68 3919.73 3919.73 E 6841.37 6841.37 veterans affairs ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1573.95 1573.95 veterans affairs veterans affairs plan "Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility" cpt 96376 21270.9 21270.9 988.09 988.09 15790.75 15790.75 13158.96 13158.96 E 1573.95 1573.95 veterans affairs ppo Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 2.63 2.63 veterans affairs veterans affairs plan Blood glucose (sugar) level cpt 82947 7.28 7.28 2.63 2.63 39.17 39.17 32.64 32.64 O 2.63 2.63 veterans affairs ppo "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 5.69 5.69 veterans affairs veterans affairs plan "Stool culture, additional pathogens" cpt 87046 35.46 35.46 5.69 5.69 56.72 56.72 47.27 47.27 O 5.69 5.69 veterans affairs ppo "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1077.63 1077.63 veterans affairs veterans affairs plan "Injection of different drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96375 3931.6 3931.6 677.23 677.23 7636.26 7636.26 6363.55 6363.55 E 1077.63 1077.63 veterans affairs ppo cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 12934.28 12934.28 veterans affairs veterans affairs plan cefazolin sodium injection cpt J0690 19270.59 19270.59 2269.35 2269.35 22085.86 22085.86 18404.88 18404.88 O 12934.28 12934.28 veterans affairs ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 38.26 38.26 veterans affairs veterans affairs plan Blood glucose (sugar) test performed by hand-held instrument cpt 82962 38.26 38.26 2.92 2.92 45.91 45.91 38.26 38.26 O 38.26 38.26 veterans affairs ppo "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 20.14 20.14 veterans affairs veterans affairs plan "X-ray of lower leg, 2 views" cpt 73590 178.64 178.64 18.86 18.86 272.21 272.21 226.84 226.84 E 20.14 20.14 veterans affairs ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 319.86 319.86 veterans affairs veterans affairs plan SARS-COV-2 COVID-19 AMP PRB cpt 87635 3587.65 3587.65 249.39 249.39 5548.68 5548.68 4623.9 4623.9 E 319.86 319.86 veterans affairs ppo ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 329.79 329.79 veterans affairs veterans affairs plan ceftriaxone sodium injection cpt J0696 2110.35 2110.35 197.85 197.85 5644.36 5644.36 4703.63 4703.63 E 329.79 329.79 veterans affairs ppo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 6276.26 6276.26 veterans affairs veterans affairs plan red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 6276.26 6276.26 veterans affairs ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 25.58 25.58 384.14 384.14 320.12 320.12 E 29.09 29.09 veterans affairs veterans affairs plan "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 25.58 25.58 384.14 384.14 320.12 320.12 E 29.09 29.09 veterans affairs ppo "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 688.83 688.83 veterans affairs veterans affairs plan "Injection of drug or substance into a vein for therapy, diagnosis, or prevention" cpt 96374 3514.38 3514.38 601.44 601.44 5094.24 5094.24 4245.2 4245.2 E 688.83 688.83 veterans affairs ppo "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 22.18 22.18 veterans affairs veterans affairs plan "X-ray of ankle, minimum of 3 views" cpt 73610 221.81 221.81 21.31 21.31 354.89 354.89 295.74 295.74 E 22.18 22.18 veterans affairs ppo Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 5.69 5.69 veterans affairs veterans affairs plan Stool culture cpt 87045 53.98 53.98 5.69 5.69 86.36 86.36 71.97 71.97 O 5.69 5.69 veterans affairs ppo prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 6841.37 6841.37 veterans affairs veterans affairs plan prochlorperazine injection cpt J0780 6841.37 6841.37 518.15 518.15 4145 4145 3454.17 3454.17 E 6841.37 6841.37 veterans affairs ppo prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 8029.89 8029.89 veterans affairs veterans affairs plan prochlorperazine injection cpt J0780 8029.89 8029.89 56.46 56.46 5245 5245 4370.83 4370.83 O 8029.89 8029.89 veterans affairs ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 veterans affairs veterans affairs plan SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 51.31 51.31 veterans affairs ppo "injection, dalbavancin" cpt J0875 4878.62 4878.62 2187.19 2187.19 11412.58 11412.58 9510.48 9510.48 E 2738.51 2738.51 veterans affairs veterans affairs plan "injection, dalbavancin" cpt J0875 4878.62 4878.62 2187.19 2187.19 11412.58 11412.58 9510.48 9510.48 E 2738.51 2738.51 veterans affairs ppo Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 3.08 3.08 veterans affairs veterans affairs plan Blood creatinine level cpt 82565 27.03 27.03 3.08 3.08 32.44 32.44 27.03 27.03 E 3.08 3.08 veterans affairs ppo "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 254.75 254.75 veterans affairs veterans affairs plan "Injection beneath the skin or into muscle for therapy, diagnosis, or prevention" cpt 96372 2102.95 2102.95 197.85 197.85 6005.21 6005.21 5004.34 5004.34 E 254.75 254.75 veterans affairs ppo Injection of anesthetic agent and/or steroid into other peripheral nerve or branch cpt 64450 791.56 791.56 261.74 261.74 1660.08 1660.08 1383.4 1383.4 O 261.74 261.74 veterans affairs veterans affairs plan Injection of anesthetic agent and/or steroid into other peripheral nerve or branch cpt 64450 791.56 791.56 261.74 261.74 1660.08 1660.08 1383.4 1383.4 O 261.74 261.74 veterans affairs ppo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 128.21 128.21 veterans affairs veterans affairs plan MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 128.21 128.21 veterans affairs ppo methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 261.74 261.74 veterans affairs veterans affairs plan methylprednisolone 40 mg inj cpt J1030 1477.69 1477.69 165.81 165.81 1671.17 1671.17 1392.64 1392.64 O 261.74 261.74 veterans affairs ppo "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 20.57 20.57 veterans affairs veterans affairs plan "X-ray of foot, minimum of 3 views" cpt 73630 258.78 258.78 20.35 20.35 354.89 354.89 295.74 295.74 E 20.57 20.57 veterans affairs ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 9.08 9.08 veterans affairs veterans affairs plan Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 9.08 9.08 veterans affairs ppo als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 549.41 549.41 veterans affairs veterans affairs plan als1-emergency cpt A0427 750.44 750.44 357.95 357.95 1709.57 1709.57 1424.64 1424.64 O 549.41 549.41 veterans affairs ppo dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 197.85 197.85 veterans affairs veterans affairs plan dexamethasone sodium phos cpt J1100 10844.92 10844.92 197.85 197.85 1351.63 1351.63 1126.36 1126.36 E 197.85 197.85 veterans affairs ppo MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 veterans affairs veterans affairs plan MRI scan of lower spinal canal cpt 72148 1688.63 1688.63 121.82 121.82 3107.5 3107.5 2589.58 2589.58 E 206.45 206.45 veterans affairs ppo Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 7417.71 7417.71 veterans affairs veterans affairs plan Removal of skin and tissue first 20 sq cm or less cpt 11042 7417.71 7417.71 277.65 277.65 1395.25 1395.25 1162.71 1162.71 O 7417.71 7417.71 veterans affairs ppo dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 11420.91 11420.91 veterans affairs veterans affairs plan dexamethasone sodium phos cpt J1100 11420.91 11420.91 2351.21 2351.21 22005.6 22005.6 18338 18338 O 11420.91 11420.91 veterans affairs ppo hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 6841.37 6841.37 veterans affairs veterans affairs plan hydromorphone injection cpt J1170 21270.9 21270.9 602.83 602.83 6392.24 6392.24 5326.87 5326.87 E 6841.37 6841.37 veterans affairs ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 308.94 308.94 veterans affairs veterans affairs plan "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3914.61 3914.61 275.34 275.34 2883.62 2883.62 2403.02 2403.02 O 308.94 308.94 veterans affairs ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 10.33 10.33 veterans affairs veterans affairs plan "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 10.33 10.33 veterans affairs ppo hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 15628.14 15628.14 veterans affairs veterans affairs plan hydromorphone injection cpt J1170 19270.59 19270.59 2440.04 2440.04 24828.17 24828.17 20690.14 20690.14 O 15628.14 15628.14 veterans affairs ppo "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1908.07 1908.07 veterans affairs veterans affairs plan "Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour" cpt 96365 3225.5 3225.5 643.21 643.21 5950.79 5950.79 4958.99 4958.99 E 1908.07 1908.07 veterans affairs ppo diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 6841.37 6841.37 veterans affairs veterans affairs plan diphenhydramine hcl injectio cpt J1200 6841.37 6841.37 525.84 525.84 4076.34 4076.34 3396.95 3396.95 E 6841.37 6841.37 veterans affairs ppo Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 2738.51 2738.51 veterans affairs veterans affairs plan Hydration infusion into a vein cpt 96361 3931.6 3931.6 306.66 306.66 5644.92 5644.92 4704.1 4704.1 E 2738.51 2738.51 veterans affairs ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 5.85 5.85 veterans affairs veterans affairs plan Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 5.85 5.85 veterans affairs ppo Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 4.15 4.15 veterans affairs veterans affairs plan Lipase (fat enzyme) level cpt 83690 91.53 91.53 4.15 4.15 150.12 150.12 125.1 125.1 O 4.15 4.15 veterans affairs ppo Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 162.77 162.77 veterans affairs veterans affairs plan Hydration infusion into a vein 31 minutes to 1 hour cpt 96360 3013.18 3013.18 162.77 162.77 3699.7 3699.7 3083.08 3083.08 E 162.77 162.77 veterans affairs ppo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 5050.15 5050.15 veterans affairs veterans affairs plan septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 5050.15 5050.15 veterans affairs ppo "Removal of foreign body from tissue, accessed beneath the skin, simple" cpt 10120 635.65 635.65 381.98 381.98 1477.88 1477.88 1231.57 1231.57 E 635.65 635.65 veterans affairs veterans affairs plan "Removal of foreign body from tissue, accessed beneath the skin, simple" cpt 10120 635.65 635.65 381.98 381.98 1477.88 1477.88 1231.57 1231.57 E 635.65 635.65 veterans affairs ppo "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 113.36 113.36 veterans affairs veterans affairs plan "Emergency department visit, low to moderately severe problem" cpt 99282 195.33 195.33 103.55 103.55 297.65 297.65 248.04 248.04 E 113.36 113.36 veterans affairs ppo G6PD (enzyme) level cpt 82955 9.7 9.7 5.84 5.84 103.2 103.2 86 86 O 5.84 5.84 veterans affairs veterans affairs plan G6PD (enzyme) level cpt 82955 9.7 9.7 5.84 5.84 103.2 103.2 86 86 O 5.84 5.84 veterans affairs ppo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 86.32 86.32 veterans affairs veterans affairs plan CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 86.32 86.32 veterans affairs ppo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 31.65 31.65 veterans affairs veterans affairs plan "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 31.65 31.65 veterans affairs ppo MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 227.85 227.85 veterans affairs veterans affairs plan MRI scan of brain before and after contrast cpt 70553 2577.39 2577.39 216.51 216.51 4123.82 4123.82 3436.52 3436.52 O 227.85 227.85 veterans affairs ppo Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 4.15 4.15 veterans affairs veterans affairs plan Lipase (fat enzyme) level cpt 83690 135.92 135.92 4.15 4.15 159.12 159.12 132.6 132.6 E 4.15 4.15 veterans affairs ppo CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 119.58 119.58 veterans affairs veterans affairs plan CT scan of neck with contrast cpt 70491 408.55 408.55 111.96 111.96 1507.32 1507.32 1256.1 1256.1 O 119.58 119.58 veterans affairs ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 3.91 3.91 veterans affairs veterans affairs plan Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 3.91 3.91 veterans affairs ppo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 7.51 7.51 veterans affairs veterans affairs plan "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 7.51 7.51 veterans affairs ppo Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 268.55 268.55 veterans affairs veterans affairs plan Respiratory inhaled aerosol treatment to relieve airway obstruction cpt 94645 1914.89 1914.89 268.55 268.55 2726.81 2726.81 2272.34 2272.34 E 268.55 268.55 veterans affairs ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 17.9 17.9 veterans affairs veterans affairs plan "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 17.9 17.9 veterans affairs ppo Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 285.24 285.24 veterans affairs veterans affairs plan Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen cpt 94640 11447.12 11447.12 268.55 268.55 4772.35 4772.35 3976.96 3976.96 E 285.24 285.24 veterans affairs ppo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 10.21 10.21 veterans affairs veterans affairs plan "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 10.21 10.21 veterans affairs ppo surgical supplies cpt A4649 9907.54 9907.54 2386.25 2386.25 23508.36 23508.36 19590.3 19590.3 O 9907.54 9907.54 veterans affairs veterans affairs plan surgical supplies cpt A4649 9907.54 9907.54 2386.25 2386.25 23508.36 23508.36 19590.3 19590.3 O 9907.54 9907.54 veterans affairs ppo inj heparin sodium per 10 u cpt J1642 6841.37 6841.37 541.93 541.93 4972.12 4972.12 4143.43 4143.43 E 6841.37 6841.37 veterans affairs veterans affairs plan inj heparin sodium per 10 u cpt J1642 6841.37 6841.37 541.93 541.93 4972.12 4972.12 4143.43 4143.43 E 6841.37 6841.37 veterans affairs ppo inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 142.69 142.69 veterans affairs veterans affairs plan inj heparin sodium per 10 u cpt J1642 4844.02 4844.02 47.76 47.76 209.88 209.88 174.9 174.9 O 142.69 142.69 veterans affairs ppo mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 1192.31 1192.31 veterans affairs veterans affairs plan mod sedat endo service >5yrs cpt G0500 3539.01 3539.01 682.87 682.87 4454.65 4454.65 3712.21 3712.21 O 1192.31 1192.31 veterans affairs ppo Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 3.26 3.26 veterans affairs veterans affairs plan Blood creatinine level cpt 82565 27.03 27.03 3.26 3.26 32.44 32.44 27.03 27.03 O 3.26 3.26 veterans affairs ppo "X-ray of wrist, 2 views" cpt 73100 21.74 21.74 19.86 19.86 272.21 272.21 226.84 226.84 E 21.74 21.74 veterans affairs veterans affairs plan "X-ray of wrist, 2 views" cpt 73100 21.74 21.74 19.86 19.86 272.21 272.21 226.84 226.84 E 21.74 21.74 veterans affairs ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 105.56 105.56 veterans affairs veterans affairs plan Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 685.6 685.6 90.7 90.7 783.55 783.55 652.96 652.96 E 105.56 105.56 veterans affairs ppo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 3863.24 3863.24 veterans affairs veterans affairs plan gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 3863.24 3863.24 veterans affairs ppo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 25.25 25.25 veterans affairs veterans affairs plan "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 25.25 25.25 veterans affairs ppo other antepartum diagnoses without o.r. procedures with mcc ms-drg 831 8473.81 8473.81 3236.69 3236.69 13886.92 13886.92 11572.43 11572.43 I 6746.45 6746.45 veterans affairs veterans affairs plan other antepartum diagnoses without o.r. procedures with mcc ms-drg 831 8473.81 8473.81 3236.69 3236.69 13886.92 13886.92 11572.43 11572.43 I 6746.45 6746.45 veterans affairs ppo Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 8.6 8.6 veterans affairs veterans affairs plan Hepatitis C antibody measurement cpt 86803 76.32 76.32 8.6 8.6 122.11 122.11 101.76 101.76 O 8.6 8.6 veterans affairs ppo respiratory infections and inflammations with cc ms-drg 178 17495.91 17495.91 1860.14 1860.14 21426.17 21426.17 17855.14 17855.14 I 1860.14 1860.14 veterans affairs veterans affairs plan respiratory infections and inflammations with cc ms-drg 178 17495.91 17495.91 1860.14 1860.14 21426.17 21426.17 17855.14 17855.14 I 1860.14 1860.14 veterans affairs ppo ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 603.46 603.46 veterans affairs veterans affairs plan ketorolac tromethamine inj cpt J1885 1476.71 1476.71 268.55 268.55 2235.78 2235.78 1863.15 1863.15 E 603.46 603.46 veterans affairs ppo Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 1.97 1.97 veterans affairs veterans affairs plan Blood glucose (sugar) test performed by hand-held instrument cpt 82962 28.7 28.7 1.97 1.97 45.91 45.91 38.26 38.26 E 1.97 1.97 veterans affairs ppo ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 12767.84 12767.84 veterans affairs veterans affairs plan ketorolac tromethamine inj cpt J1885 19270.59 19270.59 1409.32 1409.32 7004.59 7004.59 5837.16 5837.16 O 12767.84 12767.84 veterans affairs ppo Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 12.71 12.71 veterans affairs veterans affairs plan Apolipoprotein level cpt 82172 21.09 21.09 12.71 12.71 91.58 91.58 76.32 76.32 O 12.71 12.71 veterans affairs ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 1.63 1.63 veterans affairs veterans affairs plan "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 1.63 1.63 veterans affairs ppo pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 5352.8 5352.8 veterans affairs veterans affairs plan pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 5352.8 5352.8 veterans affairs ppo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 23.34 23.34 veterans affairs veterans affairs plan "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 23.34 23.34 veterans affairs ppo chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 5183.36 5183.36 veterans affairs veterans affairs plan chronic obstructive pulmonary disease with mcc ms-drg 190 9844.32 9844.32 5103.72 5103.72 26965.48 26965.48 22471.23 22471.23 I 5183.36 5183.36 veterans affairs ppo CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 161.46 161.46 veterans affairs veterans affairs plan CT scan abdomen before and after contrast cpt 74170 2071.58 2071.58 151.18 151.18 2755.15 2755.15 2295.96 2295.96 O 161.46 161.46 veterans affairs ppo CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 101.81 101.81 veterans affairs veterans affairs plan CT scan of abdomen and pelvis cpt 74176 1708.46 1708.46 95.33 95.33 2733.53 2733.53 2277.94 2277.94 E 101.81 101.81 veterans affairs ppo chronic obstructive pulmonary disease with cc ms-drg 191 7503.57 7503.57 4026.99 4026.99 20630.96 20630.96 17192.47 17192.47 I 4803.96 4803.96 veterans affairs veterans affairs plan chronic obstructive pulmonary disease with cc ms-drg 191 7503.57 7503.57 4026.99 4026.99 20630.96 20630.96 17192.47 17192.47 I 4803.96 4803.96 veterans affairs ppo "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 33.24 33.24 veterans affairs veterans affairs plan "X-ray of both hips with pelvis, 3-4 views" cpt 73522 102.22 102.22 29.49 29.49 382.87 382.87 319.06 319.06 O 33.24 33.24 veterans affairs ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 19.5 19.5 veterans affairs veterans affairs plan "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 19.5 19.5 veterans affairs ppo "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 3.02 3.02 veterans affairs veterans affairs plan "Bilirubin level, total" cpt 82247 7.18 7.18 3.02 3.02 42 42 35 35 O 3.02 3.02 veterans affairs ppo Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 12934.28 12934.28 veterans affairs veterans affairs plan Repair of hernia using an endoscope cpt 49652 12934.28 12934.28 3941.19 3941.19 28555.19 28555.19 23795.99 23795.99 O 12934.28 12934.28 veterans affairs ppo CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 214.42 214.42 veterans affairs veterans affairs plan CT scan head or brain cpt 70450 1652.81 1652.81 61.66 61.66 2644.49 2644.49 2203.74 2203.74 E 214.42 214.42 veterans affairs ppo lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 16572.45 16572.45 veterans affairs veterans affairs plan lorazepam injection cpt J2060 16572.45 16572.45 1486.86 1486.86 17302.45 17302.45 14418.71 14418.71 O 16572.45 16572.45 veterans affairs ppo "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 3.19 3.19 veterans affairs veterans affairs plan "Liver enzyme (SGPT), level" cpt 84460 6.41 6.41 3.19 3.19 31.8 31.8 26.5 26.5 O 3.19 3.19 veterans affairs ppo simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 8375.59 8375.59 veterans affairs veterans affairs plan simple pneumonia and pleurisy with mcc ms-drg 193 25007.97 25007.97 6197.57 6197.57 32692.73 32692.73 27243.94 27243.94 I 8375.59 8375.59 veterans affairs ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 193.58 193.58 veterans affairs veterans affairs plan "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 193.58 193.58 veterans affairs ppo meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 1192.31 1192.31 veterans affairs veterans affairs plan meperidine hydrochl /100 mg cpt J2175 4701.08 4701.08 1192.31 1192.31 11006.52 11006.52 9172.1 9172.1 O 1192.31 1192.31 veterans affairs ppo CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 240.13 240.13 veterans affairs veterans affairs plan CT scan of abdomen and pelvis before and after contrast cpt 74178 2547.88 2547.88 240.13 240.13 4935.36 4935.36 4112.8 4112.8 O 240.13 240.13 veterans affairs ppo meropenem cpt J2185 14120.9 14120.9 308.94 308.94 13886.69 13886.69 11572.24 11572.24 O 308.94 308.94 veterans affairs veterans affairs plan meropenem cpt J2185 14120.9 14120.9 308.94 308.94 13886.69 13886.69 11572.24 11572.24 O 308.94 308.94 veterans affairs ppo "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 226.84 226.84 veterans affairs veterans affairs plan "X-ray of wrist, 2 views" cpt 73100 226.84 226.84 19.86 19.86 272.21 272.21 226.84 226.84 O 226.84 226.84 veterans affairs ppo inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 7492.06 7492.06 veterans affairs veterans affairs plan inj midazolam hydrochloride cpt J2250 15146.83 15146.83 2242.95 2242.95 19381.32 19381.32 16151.1 16151.1 O 7492.06 7492.06 veterans affairs ppo "Evaluation of heart rhythm monitor system implanted under skin with qualified health care professional analysis, review, and report" cpt 93291 101.06 101.06 20.37 20.37 137.38 137.38 114.48 114.48 O 40.52 40.52 veterans affairs veterans affairs plan "Evaluation of heart rhythm monitor system implanted under skin with qualified health care professional analysis, review, and report" cpt 93291 101.06 101.06 20.37 20.37 137.38 137.38 114.48 114.48 O 40.52 40.52 veterans affairs ppo tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1899.34 1899.34 veterans affairs veterans affairs plan tc99m sestamibi cpt A9500 5421.31 5421.31 600.12 600.12 8770.91 8770.91 7309.09 7309.09 O 1899.34 1899.34 veterans affairs ppo morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 688.83 688.83 veterans affairs veterans affairs plan morphine sulfate injection cpt J2270 5002.28 5002.28 688.83 688.83 7005.42 7005.42 5837.85 5837.85 E 688.83 688.83 veterans affairs ppo MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 136.2 136.2 veterans affairs veterans affairs plan MRI scan of abdomen cpt 74181 2589.58 2589.58 136.2 136.2 3107.5 3107.5 2589.58 2589.58 O 136.2 136.2 veterans affairs ppo Glucose (sugar) level on body fluid cpt 82945 108.62 108.62 3.5 3.5 124.14 124.14 103.45 103.45 E 108.62 108.62 veterans affairs veterans affairs plan Glucose (sugar) level on body fluid cpt 82945 108.62 108.62 3.5 3.5 124.14 124.14 103.45 103.45 E 108.62 108.62 veterans affairs ppo Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 7.09 7.09 veterans affairs veterans affairs plan Hepatitis B core antibody (IgM) measurement cpt 86705 23.03 23.03 7.09 7.09 107.86 107.86 89.88 89.88 O 7.09 7.09 veterans affairs ppo "other injury, poisoning and toxic effect diagnoses without mcc" ms-drg 923 27632.25 27632.25 3062.32 3062.32 22082.47 22082.47 18402.06 18402.06 I 5747.5 5747.5 veterans affairs veterans affairs plan "other injury, poisoning and toxic effect diagnoses without mcc" ms-drg 923 27632.25 27632.25 3062.32 3062.32 22082.47 22082.47 18402.06 18402.06 I 5747.5 5747.5 veterans affairs ppo Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 361.33 361.33 veterans affairs veterans affairs plan Nuclear medicine study of vessels of heart using drugs or exercise multiple studies cpt 78452 3752.4 3752.4 341.67 341.67 6003.84 6003.84 5003.2 5003.2 O 361.33 361.33 veterans affairs ppo Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 16677.02 16677.02 veterans affairs veterans affairs plan Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine cpt 63030 16677.02 16677.02 5299.29 5299.29 27792.77 27792.77 23160.64 23160.64 O 16677.02 16677.02 veterans affairs ppo olanzapine long-acting inj cpt J2358 1013.4 1013.4 462.24 462.24 5260.78 5260.78 4383.98 4383.98 E 462.24 462.24 veterans affairs veterans affairs plan olanzapine long-acting inj cpt J2358 1013.4 1013.4 462.24 462.24 5260.78 5260.78 4383.98 4383.98 E 462.24 462.24 veterans affairs ppo orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 197.85 197.85 veterans affairs veterans affairs plan orphenadrine injection cpt J2360 716.17 716.17 197.85 197.85 1354.74 1354.74 1128.95 1128.95 E 197.85 197.85 veterans affairs ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1895.64 1895.64 veterans affairs veterans affairs plan Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 1895.64 1895.64 veterans affairs ppo bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 6249.69 6249.69 veterans affairs veterans affairs plan bronchitis and asthma with cc/mcc ms-drg 202 7954.58 7954.58 3549.64 3549.64 19951.51 19951.51 16626.26 16626.26 I 6249.69 6249.69 veterans affairs ppo "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 431.63 431.63 veterans affairs veterans affairs plan "Established patient office or other outpatient, visit typically 25 minutes" cpt 99214 2005.98 2005.98 79.71 79.71 2405.64 2405.64 2004.7 2004.7 O 431.63 431.63 veterans affairs ppo connective tissue disorders without cc/mcc ms-drg 547 6345.37 6345.37 5540.41 5540.41 19645.06 19645.06 16370.88 16370.88 I 6345.37 6345.37 veterans affairs veterans affairs plan connective tissue disorders without cc/mcc ms-drg 547 6345.37 6345.37 5540.41 5540.41 19645.06 19645.06 16370.88 16370.88 I 6345.37 6345.37 veterans affairs ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 64.14 64.14 veterans affairs veterans affairs plan "Coagulation assessment blood test, plasma or whole blood" cpt 85730 118.72 118.72 5.35 5.35 142.46 142.46 118.72 118.72 E 64.14 64.14 veterans affairs ppo phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 6403.21 6403.21 veterans affairs veterans affairs plan phenylephrine hcl injection cpt J2370 23111.69 23111.69 1541.69 1541.69 25453.21 25453.21 21211.01 21211.01 O 6403.21 6403.21 veterans affairs ppo ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 1190.95 1190.95 veterans affairs veterans affairs plan ondansetron hcl injection cpt J2405 5002.28 5002.28 679.31 679.31 6400.3 6400.3 5333.58 5333.58 E 1190.95 1190.95 veterans affairs ppo Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 39.76 39.76 veterans affairs veterans affairs plan Lactic acid level cpt 83605 62.54 62.54 10.29 10.29 77.59 77.59 64.66 64.66 E 39.76 39.76 veterans affairs ppo X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 91.86 91.86 veterans affairs veterans affairs plan X-ray of upper digestive tract with double contrast cpt 74246 326.2 326.2 91.86 91.86 521.92 521.92 434.93 434.93 O 91.86 91.86 veterans affairs ppo ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 8699.8 8699.8 veterans affairs veterans affairs plan ondansetron hcl injection cpt J2405 19270.59 19270.59 2167.41 2167.41 18628.44 18628.44 15523.7 15523.7 O 8699.8 8699.8 veterans affairs ppo succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 16677.02 16677.02 veterans affairs veterans affairs plan succinycholine chloride inj cpt J0330 23111.69 23111.69 3938.98 3938.98 25931.63 25931.63 21609.69 21609.69 O 16677.02 16677.02 veterans affairs ppo "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 3.02 3.02 veterans affairs veterans affairs plan "Bilirubin level, direct" cpt 82248 27.83 27.83 3.02 3.02 44.52 44.52 37.1 37.1 O 3.02 3.02 veterans affairs ppo Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 5.27 5.27 veterans affairs veterans affairs plan Iron binding capacity cpt 83550 71.63 71.63 5.27 5.27 114.6 114.6 95.5 95.5 O 5.27 5.27 veterans affairs ppo bone diseases and arthropathies with mcc ms-drg 553 17378.1 17378.1 8579.22 8579.22 36360.38 36360.38 30300.32 30300.32 I 17378.1 17378.1 veterans affairs veterans affairs plan bone diseases and arthropathies with mcc ms-drg 553 17378.1 17378.1 8579.22 8579.22 36360.38 36360.38 30300.32 30300.32 I 17378.1 17378.1 veterans affairs ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 veterans affairs veterans affairs plan Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 8.37 8.37 veterans affairs ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 5.44 5.44 veterans affairs veterans affairs plan "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 5.44 5.44 veterans affairs ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 7.73 7.73 veterans affairs veterans affairs plan Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 1660.16 1660.16 7.73 7.73 1127.22 1127.22 939.35 939.35 O 7.73 7.73 veterans affairs ppo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 26.54 26.54 veterans affairs veterans affairs plan "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 244.22 244.22 203.52 203.52 E 26.54 26.54 veterans affairs ppo Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1367.16 1367.16 veterans affairs veterans affairs plan Fine needle aspiration of first lesion using ultrasound guidance cpt 10005 1833.84 1833.84 96.87 96.87 2794.98 2794.98 2329.15 2329.15 O 1367.16 1367.16 veterans affairs ppo Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 10179.39 10179.39 veterans affairs veterans affairs plan Infusion of chemotherapy into a vein up to 1 hour cpt 96413 10179.39 10179.39 1052.17 1052.17 21878.4 21878.4 18232 18232 O 10179.39 10179.39 veterans affairs ppo "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 6910.46 6910.46 veterans affairs veterans affairs plan "inj, propofol, 10 mg" cpt J2704 19270.59 19270.59 1379.67 1379.67 17082.98 17082.98 14235.82 14235.82 O 6910.46 6910.46 veterans affairs ppo Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 285.24 285.24 veterans affairs veterans affairs plan Routine electrocardiogram (EKG) with tracing using at least 12 leads cpt 93005 7986.58 7986.58 194.68 194.68 4684.98 4684.98 3904.15 3904.15 E 285.24 285.24 veterans affairs ppo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 311.64 311.64 veterans affairs veterans affairs plan "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1130.86 1130.86 222.96 222.96 2240.83 2240.83 1867.36 1867.36 E 311.64 311.64 veterans affairs ppo neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 14281.21 14281.21 veterans affairs veterans affairs plan neostigmine methylslfte inj cpt J2710 19270.59 19270.59 3941.08 3941.08 26610.96 26610.96 22175.8 22175.8 O 14281.21 14281.21 veterans affairs ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 49.49 49.49 veterans affairs veterans affairs plan "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 49.49 49.49 veterans affairs ppo Open treatment of broken of lower forearm bone or growth plate separation with insertion of hardware cpt 25607 16572.45 16572.45 4897.01 4897.01 36409.4 36409.4 30341.17 30341.17 O 16572.45 16572.45 veterans affairs veterans affairs plan Open treatment of broken of lower forearm bone or growth plate separation with insertion of hardware cpt 25607 16572.45 16572.45 4897.01 4897.01 36409.4 36409.4 30341.17 30341.17 O 16572.45 16572.45 veterans affairs ppo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 11.2 11.2 veterans affairs veterans affairs plan "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 11.2 11.2 veterans affairs ppo Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 311.64 311.64 veterans affairs veterans affairs plan Administration of 1 vaccine cpt 90471 1130.86 1130.86 222.96 222.96 2007.48 2007.48 1672.9 1672.9 E 311.64 311.64 veterans affairs ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 78.97 78.97 veterans affairs veterans affairs plan Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 78.97 78.97 veterans affairs ppo Syphilis detection test cpt 86592 4.77 4.77 2.99 2.99 132.29 132.29 110.24 110.24 E 2.99 2.99 veterans affairs veterans affairs plan Syphilis detection test cpt 86592 4.77 4.77 2.99 2.99 132.29 132.29 110.24 110.24 E 2.99 2.99 veterans affairs ppo Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 25835.23 25835.23 veterans affairs veterans affairs plan Spinal fusion ms-drg 460 36305.41 36305.41 17839.3 17839.3 143767.9 143767.9 119806.58 119806.58 I 25835.23 25835.23 veterans affairs ppo Body fluid cell count with cell identification cpt 89051 115.75 115.75 4.98 4.98 124.8 124.8 104 104 E 115.75 115.75 veterans affairs veterans affairs plan Body fluid cell count with cell identification cpt 89051 115.75 115.75 4.98 4.98 124.8 124.8 104 104 E 115.75 115.75 veterans affairs ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 8156.09 8156.09 veterans affairs veterans affairs plan septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 8156.09 8156.09 veterans affairs ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 48.23 48.23 veterans affairs veterans affairs plan "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 48.23 48.23 veterans affairs ppo regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1899.34 1899.34 veterans affairs veterans affairs plan regadenoson injection cpt J2785 5481.82 5481.82 603.67 603.67 8903.99 8903.99 7419.99 7419.99 O 1899.34 1899.34 veterans affairs ppo "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 377.36 377.36 veterans affairs veterans affairs plan "Special stained specimen slides to examine tissue, initial procedure" cpt 88342 377.36 377.36 58.37 58.37 452.83 452.83 377.36 377.36 O 377.36 377.36 veterans affairs ppo "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 41.49 41.49 veterans affairs veterans affairs plan "Tuberculosis test, gamma interferon" cpt 86480 236.12 236.12 33.45 33.45 377.78 377.78 314.82 314.82 O 41.49 41.49 veterans affairs ppo Preparation of tissue for examination by removing any calcium present cpt 88311 43.4 43.4 7.48 7.48 49.61 49.61 41.34 41.34 O 43.4 43.4 veterans affairs veterans affairs plan Preparation of tissue for examination by removing any calcium present cpt 88311 43.4 43.4 7.48 7.48 49.61 49.61 41.34 41.34 O 43.4 43.4 veterans affairs ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 55.57 55.57 veterans affairs veterans affairs plan "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 55.57 55.57 veterans affairs ppo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 88.01 88.01 veterans affairs veterans affairs plan "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 122.23 122.23 13.39 13.39 190.8 190.8 159 159 E 88.01 88.01 veterans affairs ppo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 226.84 226.84 veterans affairs veterans affairs plan "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 226.84 226.84 veterans affairs ppo methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 366.63 366.63 veterans affairs veterans affairs plan methylprednisolone injection cpt J2930 2087.31 2087.31 366.63 366.63 3352 3352 2793.33 2793.33 E 366.63 366.63 veterans affairs ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 8541.69 8541.69 veterans affairs veterans affairs plan percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 8541.69 8541.69 veterans affairs ppo Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 3.7 3.7 veterans affairs veterans affairs plan Rheumatoid factor analysis cpt 86430 28.7 28.7 3.7 3.7 45.91 45.91 38.26 38.26 O 3.7 3.7 veterans affairs ppo Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 6.95 6.95 veterans affairs veterans affairs plan Screening test for presence of antibody cpt 86403 37.36 37.36 5.66 5.66 59.78 59.78 49.82 49.82 O 6.95 6.95 veterans affairs ppo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 195.57 195.57 veterans affairs veterans affairs plan "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 195.57 195.57 veterans affairs ppo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 2.64 2.64 veterans affairs veterans affairs plan Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 2.64 2.64 veterans affairs ppo Pathology examination of tissue using a microscope cpt 88302 133.56 133.56 20.05 20.05 160.27 160.27 133.56 133.56 O 133.56 133.56 veterans affairs veterans affairs plan Pathology examination of tissue using a microscope cpt 88302 133.56 133.56 20.05 20.05 160.27 160.27 133.56 133.56 O 133.56 133.56 veterans affairs ppo fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 11420.91 11420.91 veterans affairs veterans affairs plan fentanyl citrate injection cpt J3010 19270.59 19270.59 2425.05 2425.05 22941.24 22941.24 19117.7 19117.7 O 11420.91 11420.91 veterans affairs ppo percutaneous cardiovascular procedures with non-drug-eluting stent with mcc or 4+ arteries or stents ms-drg 248 17786.09 17786.09 12684.86 12684.86 136939.61 136939.61 114116.34 114116.34 I 12684.86 12684.86 veterans affairs veterans affairs plan percutaneous cardiovascular procedures with non-drug-eluting stent with mcc or 4+ arteries or stents ms-drg 248 17786.09 17786.09 12684.86 12684.86 136939.61 136939.61 114116.34 114116.34 I 12684.86 12684.86 veterans affairs ppo "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 44.52 44.52 veterans affairs veterans affairs plan "Pap test, evaluation of fine needle aspirate, immediate, each additional evaluation episode" cpt 88177 52.53 52.53 4.01 4.01 53.42 53.42 44.52 44.52 O 44.52 44.52 veterans affairs ppo percutaneous cardiovascular procedures with non-drug-eluting stent without mcc ms-drg 249 19270.14 19270.14 11166.95 11166.95 79497.7 79497.7 66248.08 66248.08 I 16475.95 16475.95 veterans affairs veterans affairs plan percutaneous cardiovascular procedures with non-drug-eluting stent without mcc ms-drg 249 19270.14 19270.14 11166.95 11166.95 79497.7 79497.7 66248.08 66248.08 I 16475.95 16475.95 veterans affairs ppo Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 98.58 98.58 veterans affairs veterans affairs plan Evaluation of fine needle aspirate with interpretation and report cpt 88173 98.58 98.58 58.16 58.16 118.3 118.3 98.58 98.58 O 98.58 98.58 veterans affairs ppo Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 374.18 374.18 veterans affairs veterans affairs plan Evaluation of fine needle aspirate cpt 88172 374.18 374.18 16.56 16.56 449.02 449.02 374.18 374.18 O 374.18 374.18 veterans affairs ppo tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 482.41 482.41 veterans affairs veterans affairs plan tc99m sulfur colloid cpt A9541 4483.23 4483.23 257.14 257.14 2003.39 2003.39 1669.49 1669.49 O 482.41 482.41 veterans affairs ppo vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 7417.71 7417.71 veterans affairs veterans affairs plan vancomycin hcl injection cpt J3370 8866.76 8866.76 216.34 216.34 10270.32 10270.32 8558.6 8558.6 O 7417.71 7417.71 veterans affairs ppo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 29.37 29.37 veterans affairs veterans affairs plan Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 29.37 29.37 veterans affairs ppo "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 4.6 4.6 veterans affairs veterans affairs plan "Thyroxine (thyroid chemical), total" cpt 84436 40.46 40.46 4.6 4.6 61.08 61.08 50.9 50.9 O 4.6 4.6 veterans affairs ppo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 158.13 158.13 veterans affairs veterans affairs plan "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 158.13 158.13 veterans affairs ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 21.1 21.1 veterans affairs veterans affairs plan "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 21.1 21.1 veterans affairs ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 16.03 16.03 veterans affairs veterans affairs plan "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 16.03 16.03 veterans affairs ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 65.22 65.22 veterans affairs veterans affairs plan Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 65.22 65.22 veterans affairs ppo Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 9.74 9.74 veterans affairs veterans affairs plan Microsomal antibodies (autoantibody) measurement cpt 86376 67.61 67.61 9.74 9.74 45.41 45.41 37.84 37.84 O 9.74 9.74 veterans affairs ppo Removal of tonsils patient age 12 or over cpt 42826 7492.06 7492.06 2170.19 2170.19 19340.47 19340.47 16117.06 16117.06 O 7492.06 7492.06 veterans affairs veterans affairs plan Removal of tonsils patient age 12 or over cpt 42826 7492.06 7492.06 2170.19 2170.19 19340.47 19340.47 16117.06 16117.06 O 7492.06 7492.06 veterans affairs ppo Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 709.36 709.36 veterans affairs veterans affairs plan Drainage of abscess cpt 10060 2311.63 2311.63 251.42 251.42 1139.56 1139.56 949.63 949.63 E 709.36 709.36 veterans affairs ppo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 4656.83 4656.83 veterans affairs veterans affairs plan "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 4656.83 4656.83 veterans affairs ppo "trauma to the skin, subcutaneous tissue and breast without mcc" ms-drg 605 6119.32 6119.32 5709.83 5709.83 28864.31 28864.31 24053.59 24053.59 I 5709.83 5709.83 veterans affairs veterans affairs plan "trauma to the skin, subcutaneous tissue and breast without mcc" ms-drg 605 6119.32 6119.32 5709.83 5709.83 28864.31 28864.31 24053.59 24053.59 I 5709.83 5709.83 veterans affairs ppo "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 9.07 9.07 veterans affairs veterans affairs plan "Valproic acid level, total" cpt 80164 47.79 47.79 9.07 9.07 132.16 132.16 110.13 110.13 O 9.07 9.07 veterans affairs ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 12.08 12.08 veterans affairs veterans affairs plan "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 12.08 12.08 veterans affairs ppo drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 609.71 609.71 veterans affairs veterans affairs plan drugs unclassified injection cpt J3490 4051.53 4051.53 429.12 429.12 14528.98 14528.98 12107.48 12107.48 O 609.71 609.71 veterans affairs ppo "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 183.23 183.23 veterans affairs veterans affairs plan "tomosynthesis, mammo" cpt G0279 537.22 537.22 129.17 129.17 720 720 600 600 O 183.23 183.23 veterans affairs ppo "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 23.49 23.49 veterans affairs veterans affairs plan "Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe technique" cpt 87651 100.97 100.97 23.49 23.49 161.54 161.54 134.62 134.62 E 23.49 23.49 veterans affairs ppo normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 518.09 518.09 veterans affairs veterans affairs plan normal saline solution infus cpt J7030 5460.04 5460.04 306.66 306.66 6472.27 6472.27 5393.56 5393.56 E 518.09 518.09 veterans affairs ppo Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 717.95 717.95 veterans affairs veterans affairs plan Injection of dye for X-ray imaging of shoulder joint cpt 23350 1560.4 1560.4 665.72 665.72 5407.96 5407.96 4506.63 4506.63 O 717.95 717.95 veterans affairs ppo Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 4.34 4.34 veterans affairs veterans affairs plan Glutamyltransferase (liver enzyme) level cpt 82977 30.13 30.13 4.34 4.34 43.32 43.32 36.1 36.1 O 4.34 4.34 veterans affairs ppo "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 81.62 81.62 veterans affairs veterans affairs plan "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" cpt 87641 81.62 81.62 26.28 26.28 102.84 102.84 85.7 85.7 O 81.62 81.62 veterans affairs ppo "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 952.49 952.49 veterans affairs veterans affairs plan "gad-base mr contrast nos,1ml" cpt A9579 2833.93 2833.93 332.86 332.86 4399.94 4399.94 3666.62 3666.62 O 952.49 952.49 veterans affairs ppo "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 118.72 118.72 veterans affairs veterans affairs plan "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" cpt 87640 118.72 118.72 31.21 31.21 142.46 142.46 118.72 118.72 O 118.72 118.72 veterans affairs ppo normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1513.32 1513.32 veterans affairs veterans affairs plan normal saline solution infus cpt J7040 6865.24 6865.24 696.23 696.23 5102.34 5102.34 4251.95 4251.95 O 1513.32 1513.32 veterans affairs ppo "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 10.8 10.8 veterans affairs veterans affairs plan "Measurement of antibody for assessment of autoimmune disorder, any method" cpt 86235 29.53 29.53 8.28 8.28 44.57 44.57 37.14 37.14 O 10.8 10.8 veterans affairs ppo Opiates levels cpt 80361 67.84 67.84 2.18 2.18 85.48 85.48 71.23 71.23 O 67.84 67.84 veterans affairs veterans affairs plan Opiates levels cpt 80361 67.84 67.84 2.18 2.18 85.48 85.48 71.23 71.23 O 67.84 67.84 veterans affairs ppo Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 7.8 7.8 veterans affairs veterans affairs plan Measurement of antibody for rheumatoid arthritis assessment cpt 86200 169.34 169.34 7.8 7.8 270.94 270.94 225.78 225.78 O 7.8 7.8 veterans affairs ppo Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 16.83 16.83 veterans affairs veterans affairs plan Estradiol (hormone) level cpt 82670 112.1 112.1 16.83 16.83 179.35 179.35 149.46 149.46 O 16.83 16.83 veterans affairs ppo adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 9907.54 9907.54 veterans affairs veterans affairs plan adrenalin epinephrine inject cpt J0171 12553.76 12553.76 2249.08 2249.08 22158.58 22158.58 18465.48 18465.48 O 9907.54 9907.54 veterans affairs ppo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 21.14 21.14 veterans affairs veterans affairs plan "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 21.14 21.14 veterans affairs ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 21.14 21.14 veterans affairs veterans affairs plan "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 21.14 21.14 veterans affairs ppo ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 9907.54 9907.54 veterans affairs veterans affairs plan ringers lactate infusion cpt J7120 19270.59 19270.59 505.78 505.78 4101.9 4101.9 3418.25 3418.25 O 9907.54 9907.54 veterans affairs ppo "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 14753.37 14753.37 veterans affairs veterans affairs plan "anchor/screw bn/bn,tis/bn" cpt C1713 26638.49 26638.49 3947.72 3947.72 36740.42 36740.42 30617.02 30617.02 O 14753.37 14753.37 veterans affairs ppo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 23.98 23.98 veterans affairs veterans affairs plan "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 23.98 23.98 veterans affairs ppo "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 594.7 594.7 veterans affairs veterans affairs plan "Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs" cpt 12002 870.77 870.77 222.96 222.96 1583.29 1583.29 1319.41 1319.41 E 594.7 594.7 veterans affairs ppo prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 228.27 228.27 veterans affairs veterans affairs plan prednisone ir or dr oral 1mg cpt J7512 2048.12 2048.12 228.27 228.27 2502.85 2502.85 2085.71 2085.71 E 228.27 228.27 veterans affairs ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 5.66 5.66 veterans affairs veterans affairs plan "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 5.66 5.66 veterans affairs ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 5.66 5.66 veterans affairs veterans affairs plan "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 238.4 238.4 5.66 5.66 272.46 272.46 227.05 227.05 E 5.66 5.66 veterans affairs ppo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 28.68 28.68 veterans affairs veterans affairs plan "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 28.68 28.68 veterans affairs ppo diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 5771.8 5771.8 veterans affairs veterans affairs plan diabetes with cc ms-drg 638 26280.06 26280.06 3900.52 3900.52 23211.72 23211.72 19343.1 19343.1 I 5771.8 5771.8 veterans affairs ppo Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 15628.14 15628.14 veterans affairs veterans affairs plan Removal of gallbladder using an endoscope cpt 47562 17009.14 17009.14 3939.77 3939.77 26379.84 26379.84 21983.2 21983.2 O 15628.14 15628.14 veterans affairs ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 12.08 12.08 veterans affairs veterans affairs plan "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 12.08 12.08 veterans affairs ppo Blood sodium level cpt 84295 4.81 4.81 3.22 3.22 40.44 40.44 33.7 33.7 O 3.22 3.22 veterans affairs veterans affairs plan Blood sodium level cpt 84295 4.81 4.81 3.22 3.22 40.44 40.44 33.7 33.7 O 3.22 3.22 veterans affairs ppo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 7.71 7.71 veterans affairs veterans affairs plan Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 7.71 7.71 236.59 236.59 197.16 197.16 E 7.71 7.71 veterans affairs ppo "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 7867.71 7867.71 veterans affairs veterans affairs plan "miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc" ms-drg 640 10946.86 10946.86 5256.92 5256.92 24676.81 24676.81 20564.01 20564.01 I 7867.71 7867.71 veterans affairs ppo Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 169.49 169.49 veterans affairs veterans affairs plan Screening digital tomography of both breasts cpt 77063 169.49 169.49 21.93 21.93 198.43 198.43 165.36 165.36 O 169.49 169.49 veterans affairs ppo Obstetric blood test panel cpt 80055 108.71 108.71 108.71 108.71 271.62 271.62 226.35 226.35 E 108.71 108.71 veterans affairs veterans affairs plan Obstetric blood test panel cpt 80055 108.71 108.71 108.71 108.71 271.62 271.62 226.35 226.35 E 108.71 108.71 veterans affairs ppo Obstetric blood test panel cpt 80055 89.99 89.99 89.99 89.99 107.64 107.64 89.7 89.7 O 89.99 89.99 veterans affairs veterans affairs plan Obstetric blood test panel cpt 80055 89.99 89.99 89.99 89.99 107.64 107.64 89.7 89.7 O 89.99 89.99 veterans affairs ppo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 17.83 17.83 veterans affairs veterans affairs plan Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 17.83 17.83 veterans affairs ppo slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 13240 13240 veterans affairs veterans affairs plan slings cpt A4565 13240 13240 1472.77 1472.77 19034.96 19034.96 15862.47 15862.47 O 13240 13240 veterans affairs ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 10.22 10.22 veterans affairs veterans affairs plan "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 10.22 10.22 veterans affairs ppo "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 6.95 6.95 veterans affairs veterans affairs plan "Analysis of substance using immunoassay technique, multiple step method" cpt 83516 34.58 34.58 6.95 6.95 55.33 55.33 46.11 46.11 O 6.95 6.95 veterans affairs ppo Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 75.16 75.16 veterans affairs veterans affairs plan Radiological supervision and interpretation X-ray of shoulder joint cpt 73040 380.33 380.33 75.16 75.16 1431 1431 1192.5 1192.5 O 75.16 75.16 veterans affairs ppo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 22.45 22.45 veterans affairs veterans affairs plan "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 22.45 22.45 veterans affairs ppo Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 197.85 197.85 veterans affairs veterans affairs plan Collection of blood specimen from central or peripheral venous catheter cpt 36592 2110.35 2110.35 197.85 197.85 5696.08 5696.08 4746.73 4746.73 E 197.85 197.85 veterans affairs ppo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 37.26 37.26 veterans affairs veterans affairs plan Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 37.26 37.26 veterans affairs ppo Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1513.32 1513.32 veterans affairs veterans affairs plan Biopsy of the large bowel using an endoscope (colonoscopy) cpt 45380 3589.03 3589.03 889.62 889.62 4667.93 4667.93 3889.94 3889.94 O 1513.32 1513.32 veterans affairs ppo Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1071.04 1071.04 veterans affairs veterans affairs plan Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk cpt 45378 2708.94 2708.94 665.88 665.88 3770.44 3770.44 3142.03 3142.03 O 1071.04 1071.04 veterans affairs ppo Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 3.12 3.12 veterans affairs veterans affairs plan Measurement C-reactive protein for detection of infection or inflammation cpt 86140 45.55 45.55 3.12 3.12 72.88 72.88 60.73 60.73 O 3.12 3.12 veterans affairs ppo "Total protein level, body fluid" cpt 84157 120.42 120.42 3.56 3.56 129.84 129.84 108.2 108.2 E 120.42 120.42 veterans affairs veterans affairs plan "Total protein level, body fluid" cpt 84157 120.42 120.42 3.56 3.56 129.84 129.84 108.2 108.2 E 120.42 120.42 veterans affairs ppo "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 9.85 9.85 veterans affairs veterans affairs plan "Folic acid level, serum" cpt 82746 58.51 58.51 9.85 9.85 70.21 70.21 58.51 58.51 O 9.85 9.85 veterans affairs ppo inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10179.39 10179.39 veterans affairs veterans affairs plan inj pembrolizumab cpt J9271 26265.21 26265.21 7502.28 7502.28 42024.34 42024.34 35020.28 35020.28 O 10179.39 10179.39 veterans affairs ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 8.06 8.06 veterans affairs veterans affairs plan "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 8.06 8.06 veterans affairs ppo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 5810.53 5810.53 veterans affairs veterans affairs plan disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 5810.53 5810.53 veterans affairs ppo "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 49.49 49.49 veterans affairs veterans affairs plan "X-ray of chest, 1 view" cpt 71045 151.85 151.85 13.77 13.77 242.95 242.95 202.46 202.46 E 49.49 49.49 veterans affairs ppo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 128.65 128.65 veterans affairs veterans affairs plan Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 128.65 128.65 veterans affairs ppo "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2411.66 2411.66 veterans affairs veterans affairs plan "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43239 3539.01 3539.01 696.23 696.23 4804.01 4804.01 4003.34 4003.34 O 2411.66 2411.66 veterans affairs ppo Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 7.58 7.58 veterans affairs veterans affairs plan Haptoglobin (serum protein) level cpt 83010 12.63 12.63 7.58 7.58 91.58 91.58 76.32 76.32 O 7.58 7.58 veterans affairs ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 12.08 12.08 veterans affairs veterans affairs plan "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 12.08 12.08 veterans affairs ppo drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 330.05 330.05 veterans affairs veterans affairs plan drug test def 1-7 classes cpt G0480 5714.16 5714.16 330.05 330.05 4392.84 4392.84 3660.7 3660.7 E 330.05 330.05 veterans affairs ppo Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 7.22 7.22 veterans affairs veterans affairs plan Detection test by immunoassay technique for bacteria toxin (shiga-like toxin) cpt 87427 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 7.22 7.22 veterans affairs ppo renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 9642.9 9642.9 veterans affairs veterans affairs plan renal failure with mcc ms-drg 682 14766.63 14766.63 7096.73 7096.73 29039.57 29039.57 24199.64 24199.64 I 9642.9 9642.9 veterans affairs ppo laparoscopic cholecystectomy without c.d.e. with mcc ms-drg 417 13810.6 13810.6 10906.98 10906.98 46700.2 46700.2 38916.83 38916.83 I 12596.22 12596.22 veterans affairs veterans affairs plan laparoscopic cholecystectomy without c.d.e. with mcc ms-drg 417 13810.6 13810.6 10906.98 10906.98 46700.2 46700.2 38916.83 38916.83 I 12596.22 12596.22 veterans affairs ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 9.8 9.8 veterans affairs veterans affairs plan "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 9.8 9.8 veterans affairs ppo renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6019.26 6019.26 veterans affairs veterans affairs plan renal failure with cc ms-drg 683 8376.57 8376.57 4149.28 4149.28 20393.95 20393.95 16994.96 16994.96 I 6019.26 6019.26 veterans affairs ppo "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 1010.54 1010.54 veterans affairs veterans affairs plan "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" cpt 43235 1810.27 1810.27 696.23 696.23 3668.42 3668.42 3057.02 3057.02 O 1010.54 1010.54 veterans affairs ppo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 14.51 14.51 veterans affairs veterans affairs plan Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 14.51 14.51 veterans affairs ppo adenosine inj 1mg cpt J0153 1952.13 1952.13 162.77 162.77 6062.33 6062.33 5051.94 5051.94 E 162.77 162.77 veterans affairs veterans affairs plan adenosine inj 1mg cpt J0153 1952.13 1952.13 162.77 162.77 6062.33 6062.33 5051.94 5051.94 E 162.77 162.77 veterans affairs ppo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 12.57 12.57 veterans affairs veterans affairs plan Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 12.57 12.57 veterans affairs ppo "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 23.34 23.34 veterans affairs veterans affairs plan "X-ray of hand, minimum of 3 views" cpt 73130 221.81 221.81 20.77 20.77 354.89 354.89 295.74 295.74 E 23.34 23.34 veterans affairs ppo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 8.66 8.66 veterans affairs veterans affairs plan "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 8.66 8.66 veterans affairs ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 veterans affairs veterans affairs plan Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 88.57 88.57 veterans affairs ppo Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 1.36 1.36 veterans affairs veterans affairs plan Automated urinalysis test cpt 81003 37.84 37.84 1.36 1.36 43.25 43.25 36.04 36.04 E 1.36 1.36 veterans affairs ppo "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 2.65 2.65 veterans affairs veterans affairs plan "Urea nitrogen level to assess kidney function, quantitative" cpt 84520 8.36 8.36 2.65 2.65 43.25 43.25 36.04 36.04 O 2.65 2.65 veterans affairs ppo "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 213.69 213.69 veterans affairs veterans affairs plan "X-ray of spine, 1 view" cpt 72020 213.69 213.69 12.95 12.95 244.22 244.22 203.52 203.52 O 213.69 213.69 veterans affairs ppo Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 274.65 274.65 veterans affairs veterans affairs plan Stomach emptying study cpt 78264 756.88 756.88 257.14 257.14 1658.69 1658.69 1382.24 1382.24 O 274.65 274.65 veterans affairs ppo Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 2796.74 2796.74 veterans affairs veterans affairs plan Puncture of skin for collection of blood sample cpt 36416 2796.74 2796.74 32.13 32.13 5087.64 5087.64 4239.7 4239.7 O 2796.74 2796.74 veterans affairs ppo Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 107.03 107.03 veterans affairs veterans affairs plan Diagnostic mammography of both breasts cpt 77066 208.15 208.15 100.44 100.44 304.01 304.01 253.34 253.34 O 107.03 107.03 veterans affairs ppo Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 7.22 7.22 veterans affairs veterans affairs plan Detection test by immunoassay technique for adenovirus enteric types 40/41 cpt 87301 40.46 40.46 7.22 7.22 64.74 64.74 53.95 53.95 O 7.22 7.22 veterans affairs ppo "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 87.67 87.67 veterans affairs veterans affairs plan "Evaluation of occupational therapy, typically 45 minutes" cpt 97166 3567.98 3567.98 82.09 82.09 1782.07 1782.07 1485.06 1485.06 O 87.67 87.67 veterans affairs ppo Blood potassium level cpt 84132 11.42 11.42 3.08 3.08 31.8 31.8 26.5 26.5 O 3.08 3.08 veterans affairs veterans affairs plan Blood potassium level cpt 84132 11.42 11.42 3.08 3.08 31.8 31.8 26.5 26.5 O 3.08 3.08 veterans affairs ppo Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 1445.9 1445.9 veterans affairs veterans affairs plan Puncture of skin for collection of blood sample cpt 36416 4642.21 4642.21 716.5 716.5 7116.65 7116.65 5930.54 5930.54 E 1445.9 1445.9 veterans affairs ppo Blood chloride level cpt 82435 3.08 3.08 3.08 3.08 29.26 29.26 24.38 24.38 O 3.08 3.08 veterans affairs veterans affairs plan Blood chloride level cpt 82435 3.08 3.08 3.08 3.08 29.26 29.26 24.38 24.38 O 3.08 3.08 veterans affairs ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 1.36 1.36 veterans affairs veterans affairs plan Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 1.36 1.36 veterans affairs ppo "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 19.83 19.83 veterans affairs veterans affairs plan "X-ray of elbow, minimum of 3 views" cpt 73080 164.17 164.17 17.76 17.76 318 318 265 265 E 19.83 19.83 veterans affairs ppo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 4256.51 4256.51 veterans affairs veterans affairs plan kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 4256.51 4256.51 veterans affairs ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 242.53 242.53 veterans affairs veterans affairs plan Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 242.53 242.53 veterans affairs ppo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 133.32 133.32 veterans affairs veterans affairs plan MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 133.32 133.32 veterans affairs ppo "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 10.37 10.37 veterans affairs veterans affairs plan "Cortisol (hormone) measurement, total" cpt 82533 18.64 18.64 10.37 10.37 120.84 120.84 100.7 100.7 O 10.37 10.37 veterans affairs ppo "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 717.95 717.95 veterans affairs veterans affairs plan "locm 100-199mg/ml iodine,1ml" cpt Q9965 877.03 877.03 228.19 228.19 3466.87 3466.87 2889.06 2889.06 O 717.95 717.95 veterans affairs ppo Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 3.9 3.9 veterans affairs veterans affairs plan Iron level cpt 83540 27.83 27.83 3.9 3.9 44.52 44.52 37.1 37.1 O 3.9 3.9 veterans affairs ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 52.42 52.42 webtpa ppo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 52.42 52.42 webtpa epo "Pap test, automated thin layer preparation; automated system and manual rescreening" cpt 88175 65.52 65.52 16.03 16.03 89.86 89.86 74.88 74.88 O 52.42 52.42 webtpa pos Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 41.29 41.29 webtpa ppo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 41.29 41.29 webtpa epo Gonadotropin (reproductive hormone) analysis cpt 84703 78.71 78.71 6.69 6.69 72.5 72.5 60.42 60.42 O 41.29 41.29 webtpa pos Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.11 9.11 webtpa ppo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.11 9.11 webtpa epo Automated urinalysis test cpt 81003 9.3 9.3 1.36 1.36 14.88 14.88 12.4 12.4 O 9.11 9.11 webtpa pos Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 137.88 137.88 webtpa ppo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 137.88 137.88 webtpa epo Acute hepatitis panel cpt 80074 144.13 144.13 29.37 29.37 230.6 230.6 192.17 192.17 O 137.88 137.88 webtpa pos cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 11251.17 11251.17 webtpa ppo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 11251.17 11251.17 webtpa epo cardiac arrhythmia and conduction disorders without cc/mcc ms-drg 310 11251.17 11251.17 2923.72 2923.72 16099.55 16099.55 13416.29 13416.29 I 11251.17 11251.17 webtpa pos Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 21.52 21.52 webtpa ppo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 21.52 21.52 webtpa epo Stool analysis for blood to screen for colon tumors cpt 82270 21.52 21.52 2.64 2.64 32.44 32.44 27.03 27.03 O 21.52 21.52 webtpa pos General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 3144.74 3144.74 webtpa ppo General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 3144.74 3144.74 webtpa epo General revCode 350 3144.74 3144.74 1916.73 1916.73 6914.77 6914.77 5762.31 5762.31 O 3144.74 3144.74 webtpa pos cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 46683.8 46683.8 webtpa ppo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 46683.8 46683.8 webtpa epo cervical spinal fusion with cc ms-drg 472 50054.52 50054.52 13410.03 13410.03 74958.38 74958.38 62465.32 62465.32 I 46683.8 46683.8 webtpa pos Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 208.5 208.5 webtpa ppo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 208.5 208.5 webtpa epo Screening mammography of both breasts cpt 77067 301.25 301.25 83 83 357.43 357.43 297.86 297.86 O 208.5 208.5 webtpa pos MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1903.34 1903.34 webtpa ppo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1903.34 1903.34 webtpa epo MRI scan of arm cpt 73218 1903.34 1903.34 206.45 206.45 3107.5 3107.5 2589.58 2589.58 O 1903.34 1903.34 webtpa pos "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 217.36 217.36 webtpa ppo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 217.36 217.36 webtpa epo "X-ray of hand, minimum of 3 views" cpt 73130 232.89 232.89 20.77 20.77 334.8 334.8 279 279 O 217.36 217.36 webtpa pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 95.38 95.38 webtpa ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 95.38 95.38 webtpa epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" cpt 87661 95.38 95.38 31.21 31.21 163.5 163.5 136.25 136.25 O 95.38 95.38 webtpa pos General revCode 920 2756 2756 2756 2756 4457.16 4457.16 3714.3 3714.3 O 2756 2756 webtpa ppo General revCode 920 2756 2756 2756 2756 4457.16 4457.16 3714.3 3714.3 O 2756 2756 webtpa epo General revCode 920 2756 2756 2756 2756 4457.16 4457.16 3714.3 3714.3 O 2756 2756 webtpa pos vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 4588.22 4588.22 webtpa ppo vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 4588.22 4588.22 webtpa epo vaginal delivery with o.r. procedures except sterilization and/or d&c ms-drg 768 9464.17 9464.17 2050.49 2050.49 12508.94 12508.94 10424.12 10424.12 I 4588.22 4588.22 webtpa pos "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 71.97 71.97 webtpa ppo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 71.97 71.97 webtpa epo "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" cpt 87660 77.12 77.12 12.08 12.08 123.38 123.38 102.82 102.82 O 71.97 71.97 webtpa pos Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 149.46 149.46 webtpa ppo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 149.46 149.46 webtpa epo Gonadotropin (reproductive hormone) analysis cpt 84703 149.46 149.46 6.69 6.69 147.04 147.04 122.53 122.53 E 149.46 149.46 webtpa pos "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 40.96 40.96 webtpa ppo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 40.96 40.96 webtpa epo "Bacterial culture, any other source except urine, blood or stool, aerobic" cpt 87070 43.88 43.88 5.77 5.77 70.21 70.21 58.51 58.51 O 40.96 40.96 webtpa pos Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 5003.5 5003.5 webtpa ppo Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 5003.5 5003.5 webtpa epo Diagnostic radiopharmaceuticals revCode 343 5003.5 5003.5 3200.73 3200.73 18038.66 18038.66 15032.22 15032.22 O 5003.5 5003.5 webtpa pos "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 166.73 166.73 webtpa ppo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 166.73 166.73 webtpa epo "X-ray of shoulder, minimum of 2 views" cpt 73030 178.64 178.64 19.75 19.75 256.8 256.8 214 214 O 166.73 166.73 webtpa pos "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.67 67.67 webtpa ppo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.67 67.67 webtpa epo "Detection test for candida species (yeast), direct probe technique" cpt 87480 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.67 67.67 webtpa pos Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3148.29 3148.29 webtpa ppo Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3148.29 3148.29 webtpa epo Diagnostic revCode 341 3200.73 3200.73 3148.29 3148.29 15974.16 15974.16 13311.8 13311.8 O 3148.29 3148.29 webtpa pos minor skin disorders without mcc ms-drg 607 5526.24 5526.24 2222.6 2222.6 11361.04 11361.04 9467.53 9467.53 I 3934.49 3934.49 webtpa ppo minor skin disorders without mcc ms-drg 607 5526.24 5526.24 2222.6 2222.6 11361.04 11361.04 9467.53 9467.53 I 3934.49 3934.49 webtpa epo minor skin disorders without mcc ms-drg 607 5526.24 5526.24 2222.6 2222.6 11361.04 11361.04 9467.53 9467.53 I 3934.49 3934.49 webtpa pos CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 796.91 796.91 webtpa ppo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 796.91 796.91 webtpa epo CT scan of arm cpt 73200 1195.36 1195.36 97.7 97.7 1366.13 1366.13 1138.44 1138.44 O 796.91 796.91 webtpa pos "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 57.13 57.13 webtpa ppo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 57.13 57.13 webtpa epo "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" cpt 86300 77.89 77.89 18.51 18.51 97.94 97.94 81.62 81.62 O 57.13 57.13 webtpa pos Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 10759.16 10759.16 webtpa ppo Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 10759.16 10759.16 webtpa epo Chemotherapy administration revCode 335 10759.16 10759.16 3913.9 3913.9 19348.8 19348.8 16124 16124 O 10759.16 10759.16 webtpa pos MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1903.34 1903.34 webtpa ppo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1903.34 1903.34 webtpa epo MRI scan of middle spinal canal cpt 72146 1933.28 1933.28 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1903.34 1903.34 webtpa pos "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 403.57 403.57 webtpa ppo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 403.57 403.57 webtpa epo "Ultrasound re-evaluation of pregnant uterus, per fetus" cpt 76816 411.81 411.81 59.85 59.85 658.9 658.9 549.08 549.08 O 403.57 403.57 webtpa pos "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 15507.2 15507.2 webtpa ppo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 15507.2 15507.2 webtpa epo "esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc" ms-drg 392 15507.2 15507.2 2961.25 2961.25 20252.21 20252.21 16876.84 16876.84 I 15507.2 15507.2 webtpa pos Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 10826.07 10826.07 webtpa ppo Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 10826.07 10826.07 webtpa epo Observation hours revCode 762 10826.07 10826.07 1775.61 1775.61 17738.81 17738.81 14782.34 14782.34 O 10826.07 10826.07 webtpa pos "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 43.35 43.35 webtpa ppo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 43.35 43.35 webtpa epo "Gonadotropin, chorionic (reproductive hormone) level" cpt 84702 60.42 60.42 13.39 13.39 72.5 72.5 60.42 60.42 O 43.35 43.35 webtpa pos Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 48.3 48.3 webtpa ppo Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 48.3 48.3 webtpa epo Infrared analysis of stone cpt 82365 48.3 48.3 11.47 11.47 78.86 78.86 65.72 65.72 O 48.3 48.3 webtpa pos "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 349.02 349.02 webtpa ppo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 349.02 349.02 webtpa epo "Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes" cpt 97113 3812.03 3812.03 349.02 349.02 2948.4 2948.4 2457 2457 O 349.02 349.02 webtpa pos "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 20.67 20.67 webtpa ppo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 20.67 20.67 webtpa epo "Hemoglobin analysis and measurement, chromatography" cpt 83021 88.25 88.25 15.73 15.73 141.19 141.19 117.66 117.66 O 20.67 20.67 webtpa pos "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 625.93 625.93 webtpa ppo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 625.93 625.93 webtpa epo "Ultrasound of abdomen, complete" cpt 76700 654.29 654.29 68.57 68.57 1046.86 1046.86 872.38 872.38 O 625.93 625.93 webtpa pos revision of hip or knee replacement with cc ms-drg 467 117942.4 117942.4 14037.35 14037.35 102567.41 102567.41 85472.84 85472.84 I 117942.4 117942.4 webtpa ppo revision of hip or knee replacement with cc ms-drg 467 117942.4 117942.4 14037.35 14037.35 102567.41 102567.41 85472.84 85472.84 I 117942.4 117942.4 webtpa epo revision of hip or knee replacement with cc ms-drg 467 117942.4 117942.4 14037.35 14037.35 102567.41 102567.41 85472.84 85472.84 I 117942.4 117942.4 webtpa pos MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 1794.6 1794.6 webtpa ppo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 1794.6 1794.6 webtpa epo MRI scan brain cpt 70551 2039.29 2039.29 128.4 128.4 3107.5 3107.5 2589.58 2589.58 O 1794.6 1794.6 webtpa pos "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 145.43 145.43 webtpa ppo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 145.43 145.43 webtpa epo "X-ray of knee, 1 or 2 views" cpt 73560 145.43 145.43 20.17 20.17 116 116 96.67 96.67 O 145.43 145.43 webtpa pos "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 85.33 85.33 webtpa ppo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 85.33 85.33 webtpa epo "Testosterone (hormone) level, total" cpt 84403 91.43 91.43 22.96 22.96 146.28 146.28 121.9 121.9 O 85.33 85.33 webtpa pos postoperative or post-traumatic infections with o.r. procedures with cc ms-drg 857 17726.82 17726.82 10988.1 10988.1 68981.11 68981.11 57484.26 57484.26 I 17726.82 17726.82 webtpa ppo postoperative or post-traumatic infections with o.r. procedures with cc ms-drg 857 17726.82 17726.82 10988.1 10988.1 68981.11 68981.11 57484.26 57484.26 I 17726.82 17726.82 webtpa epo postoperative or post-traumatic infections with o.r. procedures with cc ms-drg 857 17726.82 17726.82 10988.1 10988.1 68981.11 68981.11 57484.26 57484.26 I 17726.82 17726.82 webtpa pos Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 862.92 862.92 webtpa ppo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 862.92 862.92 webtpa epo Treatment room revCode 761 3117.13 3117.13 687.71 687.71 14934.65 14934.65 12445.54 12445.54 O 862.92 862.92 webtpa pos General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2750.19 2750.19 webtpa ppo General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2750.19 2750.19 webtpa epo General revCode 750 2750.19 2750.19 2204.19 2204.19 4701.28 4701.28 3917.73 3917.73 O 2750.19 2750.19 webtpa pos Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 3272.23 3272.23 webtpa ppo Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 3272.23 3272.23 webtpa epo Radiation therapy revCode 333 3272.23 3272.23 139.32 139.32 14353.2 14353.2 11961 11961 O 3272.23 3272.23 webtpa pos "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 149.58 149.58 webtpa ppo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 149.58 149.58 webtpa epo "X-ray of fingers, minimum of 2 views" cpt 73140 149.58 149.58 23.94 23.94 230.4 230.4 192 192 O 149.58 149.58 webtpa pos vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 7446.82 7446.82 webtpa ppo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 7446.82 7446.82 webtpa epo vaginal delivery without sterilization or d&c with cc ms-drg 806 8080.24 8080.24 2095.72 2095.72 14659.54 14659.54 12216.28 12216.28 I 7446.82 7446.82 webtpa pos General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 490.46 490.46 webtpa ppo General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 490.46 490.46 webtpa epo General revCode 740 4124.85 4124.85 490.46 490.46 19972.24 19972.24 16643.53 16643.53 O 490.46 490.46 webtpa pos lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 109.07 109.07 webtpa ppo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 109.07 109.07 webtpa epo lactation class cpt S9443 111.3 111.3 87.35 87.35 178.08 178.08 148.4 148.4 O 109.07 109.07 webtpa pos Holter monitor revCode 731 331.88 331.88 331.88 331.88 541.87 541.87 451.56 451.56 O 331.88 331.88 webtpa ppo Holter monitor revCode 731 331.88 331.88 331.88 331.88 541.87 541.87 451.56 451.56 O 331.88 331.88 webtpa epo Holter monitor revCode 731 331.88 331.88 331.88 331.88 541.87 541.87 451.56 451.56 O 331.88 331.88 webtpa pos cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 10349.74 10349.74 webtpa ppo cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 10349.74 10349.74 webtpa epo cesarean section without sterilization with cc ms-drg 787 10349.74 10349.74 3346.6 3346.6 16357.43 16357.43 13631.19 13631.19 I 10349.74 10349.74 webtpa pos urinary stones without mcc ms-drg 694 5014.21 5014.21 2963.72 2963.72 12824.16 12824.16 10686.8 10686.8 I 4873.85 4873.85 webtpa ppo urinary stones without mcc ms-drg 694 5014.21 5014.21 2963.72 2963.72 12824.16 12824.16 10686.8 10686.8 I 4873.85 4873.85 webtpa epo urinary stones without mcc ms-drg 694 5014.21 5014.21 2963.72 2963.72 12824.16 12824.16 10686.8 10686.8 I 4873.85 4873.85 webtpa pos "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 212.19 212.19 webtpa ppo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 212.19 212.19 webtpa epo "X-ray of wrist, minimum of 3 views" cpt 73110 232.89 232.89 25.14 25.14 116 116 96.67 96.67 O 212.19 212.19 webtpa pos General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 380.69 380.69 webtpa ppo General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 380.69 380.69 webtpa epo General revCode 730 2685.64 2685.64 380.69 380.69 11463.71 11463.71 9553.09 9553.09 O 380.69 380.69 webtpa pos "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 395.78 395.78 webtpa ppo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 395.78 395.78 webtpa epo "Radiation treatment devices, design and construction, complex" cpt 77334 403.86 403.86 57.75 57.75 646.18 646.18 538.48 538.48 O 395.78 395.78 webtpa pos Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 43 43 webtpa ppo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 43 43 webtpa epo Magnesium level cpt 83735 46.07 46.07 4.04 4.04 70.21 70.21 58.51 58.51 O 43 43 webtpa pos Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 348.64 348.64 webtpa ppo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 348.64 348.64 webtpa epo Insertion of needle into vein for collection of blood sample cpt 36415 2685.64 2685.64 23.2 23.2 498.73 498.73 415.61 415.61 O 348.64 348.64 webtpa pos "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 232.95 232.95 webtpa ppo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 232.95 232.95 webtpa epo "Bone density measurement of the core or central skeleton (e.g., hips, pelvis, spine)" cpt 77080 237.71 237.71 9.8 9.8 380.33 380.33 316.94 316.94 O 232.95 232.95 webtpa pos Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 46.27 46.27 webtpa ppo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 46.27 46.27 webtpa epo Liver function blood test panel cpt 80076 47.22 47.22 7.27 7.27 75.55 75.55 62.96 62.96 O 46.27 46.27 webtpa pos "thyroid, parathyroid and thyroglossal procedures without cc/mcc" ms-drg 627 15314.08 15314.08 15314.08 15314.08 26252.7 26252.7 21877.25 21877.25 I 15314.08 15314.08 webtpa ppo "thyroid, parathyroid and thyroglossal procedures without cc/mcc" ms-drg 627 15314.08 15314.08 15314.08 15314.08 26252.7 26252.7 21877.25 21877.25 I 15314.08 15314.08 webtpa epo "thyroid, parathyroid and thyroglossal procedures without cc/mcc" ms-drg 627 15314.08 15314.08 15314.08 15314.08 26252.7 26252.7 21877.25 21877.25 I 15314.08 15314.08 webtpa pos heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 5458.16 5458.16 webtpa ppo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 5458.16 5458.16 webtpa epo heart failure and shock with mcc ms-drg 291 21478.52 21478.52 5458.16 5458.16 29935.93 29935.93 24946.61 24946.61 I 5458.16 5458.16 webtpa pos Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 73.54 73.54 webtpa ppo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 73.54 73.54 webtpa epo Screening test for autoimmune disorder cpt 86038 75.05 75.05 7.28 7.28 113.28 113.28 94.4 94.4 O 73.54 73.54 webtpa pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 221.43 221.43 webtpa ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 221.43 221.43 webtpa epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 232.5 232.5 6.91 6.91 265.72 265.72 221.43 221.43 E 221.43 221.43 webtpa pos Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 664.19 664.19 webtpa ppo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 664.19 664.19 webtpa epo Drugs requiring detailed coding revCode 636 5378.65 5378.65 129.14 129.14 22408.99 22408.99 18674.16 18674.16 O 664.19 664.19 webtpa pos Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3168.72 3168.72 webtpa ppo Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3168.72 3168.72 webtpa epo Chemotherapy administration revCode 331 3576.75 3576.75 3168.72 3168.72 18152.71 18152.71 15127.26 15127.26 O 3168.72 3168.72 webtpa pos "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 68.24 68.24 webtpa ppo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 68.24 68.24 webtpa epo "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" cpt 87624 97.48 97.48 21.14 21.14 116.98 116.98 97.48 97.48 O 68.24 68.24 webtpa pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 77.09 77.09 webtpa ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 77.09 77.09 webtpa epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 82.6 82.6 9.05 9.05 132.16 132.16 110.13 110.13 O 77.09 77.09 webtpa pos Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 384.36 384.36 webtpa ppo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 384.36 384.36 webtpa epo Vaginal ultrasound of pregnant uterus cpt 76817 411.81 411.81 49.63 49.63 658.9 658.9 549.08 549.08 O 384.36 384.36 webtpa pos "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 385.84 385.84 webtpa ppo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 385.84 385.84 webtpa epo "X-ray of upper spine, 4 or 5 views" cpt 72050 413.4 413.4 30.83 30.83 661.44 661.44 551.2 551.2 O 385.84 385.84 webtpa pos Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 3068.09 3068.09 webtpa ppo Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 3068.09 3068.09 webtpa epo Spinal cord/spine revCode 612 5297.03 5297.03 3068.09 3068.09 6214.99 6214.99 5179.16 5179.16 O 3068.09 3068.09 webtpa pos "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 224.08 224.08 webtpa ppo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 224.08 224.08 webtpa epo "X-ray of middle spine, 3 views" cpt 72072 224.08 224.08 22.45 22.45 384.14 384.14 320.12 320.12 O 224.08 224.08 webtpa pos "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 85.33 85.33 webtpa ppo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 85.33 85.33 webtpa epo "PSA (prostate specific antigen) measurement, free" cpt 84154 85.33 85.33 16.63 16.63 146.28 146.28 121.9 121.9 O 85.33 85.33 webtpa pos Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 2644.18 2644.18 webtpa ppo Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 2644.18 2644.18 webtpa epo Brain/brain stem revCode 611 3393.18 3393.18 2644.18 2644.18 14004 14004 11670 11670 O 2644.18 2644.18 webtpa pos heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 10252.42 10252.42 webtpa ppo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 10252.42 10252.42 webtpa epo heart failure and shock with cc ms-drg 292 22045.55 22045.55 4447.05 4447.05 22970.14 22970.14 19141.78 19141.78 I 10252.42 10252.42 webtpa pos General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 2922 2922 webtpa ppo General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 2922 2922 webtpa epo General revCode 610 3269.92 3269.92 2922 2922 4211.08 4211.08 3509.23 3509.23 O 2922 2922 webtpa pos "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 92.82 92.82 webtpa ppo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 92.82 92.82 webtpa epo "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" cpt 87591 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 92.82 92.82 webtpa pos psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 331.01 331.01 webtpa ppo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 331.01 331.01 webtpa epo psa screening cpt G0103 424.12 424.12 29.78 29.78 591.17 591.17 492.64 492.64 O 331.01 331.01 webtpa pos General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 156.54 156.54 webtpa ppo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 156.54 156.54 webtpa epo General revCode 250 16775.47 16775.47 156.54 156.54 19999.5 19999.5 16666.25 16666.25 O 156.54 156.54 webtpa pos Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 1039.72 1039.72 webtpa ppo Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 1039.72 1039.72 webtpa epo Chest X revCode 324 2899.33 2899.33 993.32 993.32 14709.6 14709.6 12258 12258 O 1039.72 1039.72 webtpa pos "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 67 67 webtpa ppo "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 67 67 webtpa epo "Insulin measurement, total" cpt 83525 68.37 68.37 10.17 10.17 109.39 109.39 91.16 91.16 O 67 67 webtpa pos vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 13482.64 13482.64 webtpa ppo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 13482.64 13482.64 webtpa epo vaginal delivery without sterilization or d&c with mcc ms-drg 805 13482.64 13482.64 2649.69 2649.69 19194.61 19194.61 15995.51 15995.51 I 13482.64 13482.64 webtpa pos Urgent care clinic revCode 516 58.62 58.62 58.62 58.62 100.49 100.49 83.74 83.74 O 58.62 58.62 webtpa ppo Urgent care clinic revCode 516 58.62 58.62 58.62 58.62 100.49 100.49 83.74 83.74 O 58.62 58.62 webtpa epo Urgent care clinic revCode 516 58.62 58.62 58.62 58.62 100.49 100.49 83.74 83.74 O 58.62 58.62 webtpa pos Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 100.5 100.5 webtpa ppo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 100.5 100.5 webtpa epo Analysis for antibody to Rubeola (measles virus) cpt 86765 100.5 100.5 11.46 11.46 53.93 53.93 44.94 44.94 O 100.5 100.5 webtpa pos "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 60.3 60.3 webtpa ppo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 60.3 60.3 webtpa epo "PSA (prostate specific antigen) measurement, total" cpt 84153 61.53 61.53 16.36 16.36 98.45 98.45 82.04 82.04 O 60.3 60.3 webtpa pos intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 12287.03 12287.03 webtpa ppo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 12287.03 12287.03 webtpa epo intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours ms-drg 65 21865.72 21865.72 6193.89 6193.89 17014.63 17014.63 14178.86 14178.86 I 12287.03 12287.03 webtpa pos CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1674.28 1674.28 webtpa ppo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1674.28 1674.28 webtpa epo CT scan of abdomen and pelvis cpt 74176 1708.45 1708.45 203.15 203.15 2733.53 2733.53 2277.94 2277.94 O 1674.28 1674.28 webtpa pos "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 24.49 24.49 webtpa ppo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 24.49 24.49 webtpa epo "Red blood cell sedimentation rate, to detect inflammation, automated" cpt 85652 26.24 26.24 1.63 1.63 41.98 41.98 34.98 34.98 O 24.49 24.49 webtpa pos General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 61.55 61.55 webtpa ppo General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 61.55 61.55 webtpa epo General revCode 510 3561.8 3561.8 61.55 61.55 2348.4 2348.4 1957 1957 O 61.55 61.55 webtpa pos back and neck procedures except spinal fusion with cc ms-drg 519 36370.92 36370.92 10756.98 10756.98 60402.74 60402.74 50335.62 50335.62 I 36370.92 36370.92 webtpa ppo back and neck procedures except spinal fusion with cc ms-drg 519 36370.92 36370.92 10756.98 10756.98 60402.74 60402.74 50335.62 50335.62 I 36370.92 36370.92 webtpa epo back and neck procedures except spinal fusion with cc ms-drg 519 36370.92 36370.92 10756.98 10756.98 60402.74 60402.74 50335.62 50335.62 I 36370.92 36370.92 webtpa pos Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 278.25 278.25 webtpa ppo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 278.25 278.25 webtpa epo Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus cpt 76805 298.13 298.13 90.7 90.7 477 477 397.5 397.5 O 278.25 278.25 webtpa pos General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 27750.28 27750.28 webtpa ppo General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 27750.28 27750.28 webtpa epo General revCode 480 27750.28 27750.28 2685.64 2685.64 26808.52 26808.52 22340.43 22340.43 O 27750.28 27750.28 webtpa pos "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 149.58 149.58 webtpa ppo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 149.58 149.58 webtpa epo "X-ray of knee, 3 views" cpt 73562 160.27 160.27 24.84 24.84 230.4 230.4 192 192 O 149.58 149.58 webtpa pos "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 44.07 44.07 webtpa ppo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 44.07 44.07 webtpa epo "Blood test, basic group of blood chemicals (Calcium, total)" cpt 80048 49.58 49.58 5.66 5.66 75.55 75.55 62.96 62.96 O 44.07 44.07 webtpa pos "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1184.97 1184.97 webtpa ppo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1184.97 1184.97 webtpa epo "Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function" cpt 93306 1269.62 1269.62 113.16 113.16 2031.38 2031.38 1692.82 1692.82 O 1184.97 1184.97 webtpa pos Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 469.79 469.79 webtpa ppo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 469.79 469.79 webtpa epo Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck cpt 93880 479.39 479.39 188.57 188.57 767.02 767.02 639.18 639.18 O 469.79 469.79 webtpa pos Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 247.09 247.09 webtpa ppo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 247.09 247.09 webtpa epo Ultrasound of fetus cpt 76819 411.81 411.81 42.11 42.11 658.9 658.9 549.08 549.08 O 247.09 247.09 webtpa pos Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.03 33.03 webtpa ppo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.03 33.03 webtpa epo Analysis for antibody to Rubella (German measles virus) cpt 86762 33.71 33.71 6.66 6.66 53.93 53.93 44.94 44.94 O 33.03 33.03 webtpa pos General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 812.7 812.7 webtpa ppo General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 812.7 812.7 webtpa epo General revCode 460 6950.29 6950.29 812.7 812.7 36595.54 36595.54 30496.28 30496.28 O 812.7 812.7 webtpa pos cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 webtpa ppo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 webtpa epo cesarean section without sterilization with mcc ms-drg 786 17092.44 17092.44 4451.94 4451.94 27347.9 27347.9 22789.92 22789.92 I 8998.11 8998.11 webtpa pos "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 185.5 185.5 webtpa ppo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 185.5 185.5 webtpa epo "Established patient office or other outpatient visit, typically 15 minutes" cpt 99213 320.9 320.9 46.39 46.39 1045.49 1045.49 871.24 871.24 O 185.5 185.5 webtpa pos "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 37.77 37.77 webtpa ppo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 37.77 37.77 webtpa epo "Thyroid hormone, T3 measurement, total" cpt 84480 40.46 40.46 12.61 12.61 64.74 64.74 53.95 53.95 O 37.77 37.77 webtpa pos pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 13099.97 13099.97 webtpa ppo pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 13099.97 13099.97 webtpa epo pulmonary edema and respiratory failure ms-drg 189 13099.97 13099.97 3622.47 3622.47 35491.31 35491.31 29576.09 29576.09 I 13099.97 13099.97 webtpa pos Ultrasound scanning of blood flow (outside of brain) on one side of head and neck or limited cpt 93882 365.06 365.06 98.5 98.5 505.94 505.94 421.62 421.62 O 365.06 365.06 webtpa ppo Ultrasound scanning of blood flow (outside of brain) on one side of head and neck or limited cpt 93882 365.06 365.06 98.5 98.5 505.94 505.94 421.62 421.62 O 365.06 365.06 webtpa epo Ultrasound scanning of blood flow (outside of brain) on one side of head and neck or limited cpt 93882 365.06 365.06 98.5 98.5 505.94 505.94 421.62 421.62 O 365.06 365.06 webtpa pos MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa ppo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa epo MRI scan of arm joint cpt 73221 2039.29 2039.29 146.62 146.62 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa pos Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 468.5 468.5 webtpa ppo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 468.5 468.5 webtpa epo Ultrasound study of arteries and arterial grafts of both legs cpt 93925 468.5 468.5 184.36 184.36 783.55 783.55 652.96 652.96 O 468.5 468.5 webtpa pos "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 33.03 33.03 webtpa ppo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 33.03 33.03 webtpa epo "Uric acid level, blood" cpt 84550 78.7 78.7 2.87 2.87 53.93 53.93 44.94 44.94 O 33.03 33.03 webtpa pos "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 33.5 33.5 webtpa ppo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 33.5 33.5 webtpa epo "Coagulation assessment blood test, plasma or whole blood" cpt 85730 35.04 35.04 5.35 5.35 54.7 54.7 45.58 45.58 O 33.5 33.5 webtpa pos General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1714.61 1714.61 webtpa ppo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1714.61 1714.61 webtpa epo General revCode 450 2685.64 2685.64 663.01 663.01 5685.82 5685.82 4738.18 4738.18 O 1714.61 1714.61 webtpa pos "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 326.44 326.44 webtpa ppo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 326.44 326.44 webtpa epo "Detection test by nucleic acid for Hepatitis C virus, quantification" cpt 87522 326.44 326.44 28.68 28.68 532.97 532.97 444.14 444.14 O 326.44 326.44 webtpa pos Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 60.85 60.85 webtpa ppo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 60.85 60.85 webtpa epo Hepatitis B surface antibody measurement cpt 86706 63.6 63.6 9.55 9.55 101.76 101.76 84.8 84.8 O 60.85 60.85 webtpa pos diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 16405.35 16405.35 webtpa ppo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 16405.35 16405.35 webtpa epo diabetes with mcc ms-drg 637 17801.06 17801.06 6598.2 6598.2 39138.23 39138.23 32615.19 32615.19 I 16405.35 16405.35 webtpa pos Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 349.03 349.03 webtpa ppo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 349.03 349.03 webtpa epo Ultrasound of scrotum cpt 76870 356.16 356.16 61.67 61.67 569.86 569.86 474.88 474.88 O 349.03 349.03 webtpa pos Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 108.33 108.33 webtpa ppo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 108.33 108.33 webtpa epo Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days cpt 93270 124.38 124.38 7.84 7.84 185.71 185.71 154.76 154.76 O 108.33 108.33 webtpa pos respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 6218.17 6218.17 webtpa ppo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 6218.17 6218.17 webtpa epo respiratory infections and inflammations with mcc ms-drg 177 20820.38 20820.38 6218.17 6218.17 37441.16 37441.16 31200.97 31200.97 I 6218.17 6218.17 webtpa pos "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 46.75 46.75 webtpa ppo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 46.75 46.75 webtpa epo "Testosterone (hormone) level, free" cpt 84402 47.7 47.7 16.99 16.99 76.32 76.32 63.6 63.6 O 46.75 46.75 webtpa pos MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa ppo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa epo MRI scan of leg joint cpt 73721 1986.81 1986.81 139.24 139.24 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa pos "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.14 17.14 webtpa ppo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.14 17.14 webtpa epo "Identification of organisms by immunologic analysis, other than immunofluorescence method" cpt 87147 17.49 17.49 3.46 3.46 27.98 27.98 23.32 23.32 O 17.14 17.14 webtpa pos Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 48.23 48.23 webtpa ppo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 48.23 48.23 webtpa epo Hemoglobin A1C level cpt 83036 68.9 68.9 5.72 5.72 82.68 82.68 68.9 68.9 O 48.23 48.23 webtpa pos "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 249.46 249.46 webtpa ppo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 249.46 249.46 webtpa epo "X-ray of abdomen, minimum of 3 views" cpt 74021 249.46 249.46 23.65 23.65 417.22 417.22 347.68 347.68 O 249.46 249.46 webtpa pos Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 298.28 298.28 webtpa ppo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 298.28 298.28 webtpa epo Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring cpt 93017 5285.79 5285.79 224.22 224.22 8449.04 8449.04 7040.87 7040.87 O 298.28 298.28 webtpa pos Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 66.92 66.92 webtpa ppo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 66.92 66.92 webtpa epo Vitamin D-3 level cpt 82306 68.29 68.29 17.83 17.83 109.26 109.26 91.05 91.05 O 66.92 66.92 webtpa pos Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 687.83 687.83 webtpa ppo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 687.83 687.83 webtpa epo Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers cpt 93970 773.81 773.81 136.54 136.54 1129.54 1129.54 941.28 941.28 O 687.83 687.83 webtpa pos "Ultrasound of pelvis, complete, not pregnancy related" cpt 76856 430.84 430.84 63.46 63.46 703.42 703.42 586.18 586.18 O 430.84 430.84 webtpa ppo "Ultrasound of pelvis, complete, not pregnancy related" cpt 76856 430.84 430.84 63.46 63.46 703.42 703.42 586.18 586.18 O 430.84 430.84 webtpa epo "Ultrasound of pelvis, complete, not pregnancy related" cpt 76856 430.84 430.84 63.46 63.46 703.42 703.42 586.18 586.18 O 430.84 430.84 webtpa pos "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 37.47 37.47 webtpa ppo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 37.47 37.47 webtpa epo "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" cpt 86812 63.9 63.9 17.59 17.59 109.39 109.39 91.16 91.16 O 37.47 37.47 webtpa pos CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 1092.29 1092.29 webtpa ppo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 1092.29 1092.29 webtpa epo CT scan of lower spine cpt 72131 1092.29 1092.29 99.29 99.29 1783.34 1783.34 1486.12 1486.12 O 1092.29 1092.29 webtpa pos Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 63.74 63.74 webtpa ppo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 63.74 63.74 webtpa epo Detection test by immunoassay technique for HIV-1 and HIV-2 cpt 87389 84.6 84.6 14.51 14.51 109.26 109.26 91.05 91.05 O 63.74 63.74 webtpa pos Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 23.28 23.28 webtpa ppo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 23.28 23.28 webtpa epo Screening test for pathogenic organisms cpt 87081 30.37 30.37 5.9 5.9 48.59 48.59 40.49 40.49 O 23.28 23.28 webtpa pos pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 13113.91 13113.91 webtpa ppo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 13113.91 13113.91 webtpa epo pulmonary embolism without mcc ms-drg 176 13113.91 13113.91 3391.36 3391.36 21706.12 21706.12 18088.43 18088.43 I 13113.91 13113.91 webtpa pos "shoulder, elbow or forearm procedures, except major joint procedures with cc" ms-drg 511 41222.33 41222.33 12029.58 12029.58 70758.94 70758.94 58965.78 58965.78 I 41222.33 41222.33 webtpa ppo "shoulder, elbow or forearm procedures, except major joint procedures with cc" ms-drg 511 41222.33 41222.33 12029.58 12029.58 70758.94 70758.94 58965.78 58965.78 I 41222.33 41222.33 webtpa epo "shoulder, elbow or forearm procedures, except major joint procedures with cc" ms-drg 511 41222.33 41222.33 12029.58 12029.58 70758.94 70758.94 58965.78 58965.78 I 41222.33 41222.33 webtpa pos CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 1066.29 1066.29 webtpa ppo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 1066.29 1066.29 webtpa epo CT scan chest cpt 71250 1066.29 1066.29 97.4 97.4 1783.34 1783.34 1486.12 1486.12 O 1066.29 1066.29 webtpa pos "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 258.42 258.42 webtpa ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 258.42 258.42 webtpa epo "Blood test, comprehensive group of blood chemicals" cpt 80053 415.61 415.61 9.39 9.39 310.1 310.1 258.42 258.42 E 258.42 258.42 webtpa pos "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 35.39 35.39 webtpa ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 35.39 35.39 webtpa epo "Complete blood cell count (red cells, white blood cell, platelets), automated test" cpt 85027 50.56 50.56 5.75 5.75 60.67 60.67 50.56 50.56 O 35.39 35.39 webtpa pos "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 444.09 444.09 webtpa ppo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 444.09 444.09 webtpa epo "New patient office or other outpatient visit, typically 45 minutes" cpt 99204 1368.51 1368.51 147.84 147.84 1456.69 1456.69 1213.91 1213.91 O 444.09 444.09 webtpa pos other antepartum diagnoses without o.r. procedures with mcc ms-drg 831 8473.81 8473.81 3236.69 3236.69 13886.92 13886.92 11572.43 11572.43 I 8473.81 8473.81 webtpa ppo other antepartum diagnoses without o.r. procedures with mcc ms-drg 831 8473.81 8473.81 3236.69 3236.69 13886.92 13886.92 11572.43 11572.43 I 8473.81 8473.81 webtpa epo other antepartum diagnoses without o.r. procedures with mcc ms-drg 831 8473.81 8473.81 3236.69 3236.69 13886.92 13886.92 11572.43 11572.43 I 8473.81 8473.81 webtpa pos "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 71.9 71.9 webtpa ppo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 71.9 71.9 webtpa epo "Thyroid hormone, T3 measurement, free" cpt 84481 73.37 73.37 10.21 10.21 117.4 117.4 97.83 97.83 O 71.9 71.9 webtpa pos "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 79.4 79.4 webtpa ppo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 79.4 79.4 webtpa epo "Analysis for antibody to Herpes simplex virus, type 2" cpt 86696 204.66 204.66 17.21 17.21 136.1 136.1 113.42 113.42 O 79.4 79.4 webtpa pos disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 18279.29 18279.29 webtpa ppo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 18279.29 18279.29 webtpa epo disorders of pancreas except malignancy with cc ms-drg 439 18279.29 18279.29 4142.79 4142.79 19675.4 19675.4 16396.17 16396.17 I 18279.29 18279.29 webtpa pos Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 479.92 479.92 webtpa ppo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 479.92 479.92 webtpa epo Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers cpt 93971 515.96 515.96 90.7 90.7 783.55 783.55 652.96 652.96 O 479.92 479.92 webtpa pos "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 216.66 216.66 webtpa ppo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 216.66 216.66 webtpa epo "X-ray of chest, 2 views" cpt 71046 232.14 232.14 18.26 18.26 371.42 371.42 309.52 309.52 O 216.66 216.66 webtpa pos Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1977.77 1977.77 webtpa ppo Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1977.77 1977.77 webtpa epo Visit charge revCode 431 1977.77 1977.77 138.67 138.67 4487.62 4487.62 3739.68 3739.68 O 1977.77 1977.77 webtpa pos pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 50462.72 50462.72 webtpa ppo pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 50462.72 50462.72 webtpa epo pulmonary embolism with mcc or acute cor pulmonale ms-drg 175 50462.72 50462.72 7416.41 7416.41 41944.68 41944.68 34953.9 34953.9 I 50462.72 50462.72 webtpa pos "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 224.08 224.08 webtpa ppo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 224.08 224.08 webtpa epo "X-ray of ribs on one side of body including the chest, minimum of 3 views" cpt 71101 224.08 224.08 21.67 21.67 384.14 384.14 320.12 320.12 O 224.08 224.08 webtpa pos Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 263 263 webtpa ppo Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 263 263 webtpa epo Evaluation or reevaluation revCode 424 1044.94 1044.94 136.89 136.89 2814.5 2814.5 2345.42 2345.42 O 263 263 webtpa pos Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 7.08 7.08 webtpa ppo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 7.08 7.08 webtpa epo Red blood cell concentration measurement cpt 85014 30.21 30.21 2.11 2.11 45.6 45.6 38 38 O 7.08 7.08 webtpa pos "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 60.3 60.3 webtpa ppo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 60.3 60.3 webtpa epo "Blood test, comprehensive group of blood chemicals" cpt 80053 61.53 61.53 9.39 9.39 98.45 98.45 82.04 82.04 O 60.3 60.3 webtpa pos major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 32467.31 32467.31 webtpa ppo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 32467.31 32467.31 webtpa epo major small and large bowel procedures with cc ms-drg 330 59746.02 59746.02 14048.11 14048.11 67900.68 67900.68 56583.9 56583.9 I 32467.31 32467.31 webtpa pos "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 177.63 177.63 webtpa ppo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 177.63 177.63 webtpa epo "X-ray of abdomen, 1 view" cpt 74018 181.26 181.26 16.26 16.26 290.02 290.02 241.68 241.68 O 177.63 177.63 webtpa pos respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 85116 85116 webtpa ppo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 85116 85116 webtpa epo respiratory system diagnosis with ventilator support >96 hours ms-drg 207 173837.62 173837.62 912.58 912.58 169745.27 169745.27 141454.39 141454.39 I 85116 85116 webtpa pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 24.15 24.15 webtpa ppo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 24.15 24.15 webtpa epo Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 24.15 24.15 webtpa pos "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.67 67.67 webtpa ppo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.67 67.67 webtpa epo "Detection test for gardnerella vaginalis (bacteria), direct probe technique" cpt 87510 72.5 72.5 12.08 12.08 116 116 96.67 96.67 O 67.67 67.67 webtpa pos Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 39.92 39.92 webtpa ppo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 39.92 39.92 webtpa epo Progesterone (reproductive hormone) level cpt 84144 68.37 68.37 12.57 12.57 109.39 109.39 91.16 91.16 O 39.92 39.92 webtpa pos "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 3.17 3.17 webtpa ppo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 3.17 3.17 webtpa epo "Red blood cell count, automated test" cpt 85041 13.52 13.52 2.27 2.27 21.62 21.62 18.02 18.02 O 3.17 3.17 webtpa pos Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 574 574 webtpa ppo Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 574 574 webtpa epo Peripheral vascular lab revCode 921 2997.13 2997.13 489.26 489.26 14875.3 14875.3 12396.08 12396.08 O 574 574 webtpa pos Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 2253.92 2253.92 webtpa ppo Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 2253.92 2253.92 webtpa epo Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 2253.92 2253.92 webtpa pos Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 238.92 238.92 webtpa ppo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 238.92 238.92 webtpa epo Complete ultrasound of arm or leg cpt 76881 282.79 282.79 39.56 39.56 409.58 409.58 341.32 341.32 O 238.92 238.92 webtpa pos General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3778.97 3778.97 webtpa ppo General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3778.97 3778.97 webtpa epo General revCode 420 3778.97 3778.97 3098.67 3098.67 6602.4 6602.4 5502 5502 O 3778.97 3778.97 webtpa pos septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 9053.89 9053.89 webtpa ppo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 9053.89 9053.89 webtpa epo septicemia or severe sepsis without mv >96 hours with mcc ms-drg 871 18280.29 18280.29 8156.09 8156.09 43218.12 43218.12 36015.1 36015.1 I 9053.89 9053.89 webtpa pos gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 5825.61 5825.61 webtpa ppo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 5825.61 5825.61 webtpa epo gastrointestinal obstruction with cc ms-drg 389 16489.31 16489.31 3863.24 3863.24 20166.95 20166.95 16805.79 16805.79 I 5825.61 5825.61 webtpa pos "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 56.39 56.39 webtpa ppo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 56.39 56.39 webtpa epo "Analysis for antibody to Herpes simplex virus, type 1" cpt 86695 56.39 56.39 11.73 11.73 96.67 96.67 80.56 80.56 O 56.39 56.39 webtpa pos CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 836.75 836.75 webtpa ppo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 836.75 836.75 webtpa epo CT scan of cranial cavity cpt 70480 836.75 836.75 94.12 94.12 1366.13 1366.13 1138.44 1138.44 O 836.75 836.75 webtpa pos Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.9 19.9 webtpa ppo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.9 19.9 webtpa epo Blood group typing (ABO) cpt 86900 96.59 96.59 2.66 2.66 136.1 136.1 113.42 113.42 O 19.9 19.9 webtpa pos MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 908.35 908.35 webtpa ppo MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 908.35 908.35 webtpa epo MRI scan of leg cpt 73718 978.69 978.69 183.82 183.82 3107.5 3107.5 2589.58 2589.58 O 908.35 908.35 webtpa pos Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 138.01 138.01 webtpa ppo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 138.01 138.01 webtpa epo Detection test by nucleic acid for multiple types influenza virus cpt 87502 147.87 147.87 44.91 44.91 236.59 236.59 197.16 197.16 O 138.01 138.01 webtpa pos Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 77.91 77.91 webtpa ppo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 77.91 77.91 webtpa epo Virus isolation cpt 87255 77.91 77.91 30.12 30.12 133.56 133.56 111.3 111.3 O 77.91 77.91 webtpa pos poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 14541.21 14541.21 webtpa ppo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 14541.21 14541.21 webtpa epo poisoning and toxic effects of drugs with mcc ms-drg 917 24671.23 24671.23 6543.47 6543.47 34428.73 34428.73 28690.61 28690.61 I 14541.21 14541.21 webtpa pos "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 158.47 158.47 webtpa ppo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 158.47 158.47 webtpa epo "Troponin (protein) analysis, quantitative" cpt 84484 166.39 166.39 7.51 7.51 190.16 190.16 158.47 158.47 E 158.47 158.47 webtpa pos CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 439.5 439.5 webtpa ppo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 439.5 439.5 webtpa epo CT scan leg cpt 73700 482.16 482.16 93.83 93.83 1504.78 1504.78 1253.98 1253.98 O 439.5 439.5 webtpa pos Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.22 13.22 webtpa ppo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.22 13.22 webtpa epo Blood typing for Rh (D) antigen cpt 86901 70.1 70.1 2.66 2.66 90.31 90.31 75.26 75.26 O 13.22 13.22 webtpa pos inguinal and femoral hernia procedures with cc ms-drg 351 51566.74 51566.74 7816.79 7816.79 39829.91 39829.91 33191.59 33191.59 I 51566.74 51566.74 webtpa ppo inguinal and femoral hernia procedures with cc ms-drg 351 51566.74 51566.74 7816.79 7816.79 39829.91 39829.91 33191.59 33191.59 I 51566.74 51566.74 webtpa epo inguinal and femoral hernia procedures with cc ms-drg 351 51566.74 51566.74 7816.79 7816.79 39829.91 39829.91 33191.59 33191.59 I 51566.74 51566.74 webtpa pos "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 149.07 149.07 webtpa ppo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 149.07 149.07 webtpa epo "X-ray of toes, minimum of 2 views" cpt 73660 149.07 149.07 17.96 17.96 249.31 249.31 207.76 207.76 O 149.07 149.07 webtpa pos cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 46942.95 46942.95 webtpa ppo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 46942.95 46942.95 webtpa epo cardiac valve and other major cardiothoracic procedures without cardiac catheterization with cc ms-drg 220 54699.55 54699.55 626.2 626.2 182875.63 182875.63 152396.36 152396.36 I 46942.95 46942.95 webtpa pos vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 24554.04 24554.04 webtpa ppo vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 24554.04 24554.04 webtpa epo vaginal delivery with sterilization and/or d&c without cc/mcc ms-drg 798 24554.04 24554.04 2940.28 2940.28 31170.52 31170.52 25975.43 25975.43 I 24554.04 24554.04 webtpa pos Screening mammography revCode 403 340.46 340.46 340.46 340.46 555.86 555.86 463.22 463.22 O 340.46 340.46 webtpa ppo Screening mammography revCode 403 340.46 340.46 340.46 340.46 555.86 555.86 463.22 463.22 O 340.46 340.46 webtpa epo Screening mammography revCode 403 340.46 340.46 340.46 340.46 555.86 555.86 463.22 463.22 O 340.46 340.46 webtpa pos Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 6556.08 6556.08 webtpa ppo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 6556.08 6556.08 webtpa epo Normal delivery of baby ms-drg 807 8071.15 8071.15 1850.9 1850.9 13314.88 13314.88 11095.73 11095.73 I 6556.08 6556.08 webtpa pos Stereotactic body radiation therapy 1 or more lesions using imaging guidance cpt 77373 2884.88 2884.88 1536.3 1536.3 4710 4710 3925 3925 O 2884.88 2884.88 webtpa ppo Stereotactic body radiation therapy 1 or more lesions using imaging guidance cpt 77373 2884.88 2884.88 1536.3 1536.3 4710 4710 3925 3925 O 2884.88 2884.88 webtpa epo Stereotactic body radiation therapy 1 or more lesions using imaging guidance cpt 77373 2884.88 2884.88 1536.3 1536.3 4710 4710 3925 3925 O 2884.88 2884.88 webtpa pos "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 173.63 173.63 webtpa ppo "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 173.63 173.63 webtpa epo "Emergency department visit, low to moderately severe problem" cpt 99282 370.1 370.1 173.63 173.63 297.65 297.65 248.04 248.04 O 173.63 173.63 webtpa pos "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 185.01 185.01 webtpa ppo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 185.01 185.01 webtpa epo "Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older" cpt 90714 1474.83 1474.83 185.01 185.01 1691.47 1691.47 1409.56 1409.56 O 185.01 185.01 webtpa pos Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 695.73 695.73 webtpa ppo Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 695.73 695.73 webtpa epo Ultrasound revCode 402 1775.61 1775.61 695.73 695.73 1999.38 1999.38 1666.15 1666.15 O 695.73 695.73 webtpa pos C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 7690.39 7690.39 webtpa ppo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 7690.39 7690.39 webtpa epo C-Section delivery of baby ms-drg 788 9709.02 9709.02 3004.94 3004.94 15976.34 15976.34 13313.62 13313.62 I 7690.39 7690.39 webtpa pos "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 34.74 34.74 webtpa ppo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 34.74 34.74 webtpa epo "Thyroxine (thyroid chemical), free" cpt 84439 35.45 35.45 5.44 5.44 56.72 56.72 47.27 47.27 O 34.74 34.74 webtpa pos "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 275.28 275.28 webtpa ppo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 275.28 275.28 webtpa epo "New patient office or other outpatient visit, typically 30 minutes" cpt 99203 6873.58 6873.58 205.95 205.95 1423.62 1423.62 1186.35 1186.35 O 275.28 275.28 webtpa pos cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 9682.72 9682.72 webtpa ppo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 9682.72 9682.72 webtpa epo cardiac arrhythmia and conduction disorders with cc ms-drg 309 9682.72 9682.72 3142.55 3142.55 21946.09 21946.09 18288.41 18288.41 I 9682.72 9682.72 webtpa pos "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 385.84 385.84 webtpa ppo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 385.84 385.84 webtpa epo "X-ray of lower and sacral spine, minimum of 4 views" cpt 72110 423.74 423.74 29.79 29.79 661.44 661.44 551.2 551.2 O 385.84 385.84 webtpa pos "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 79.46 79.46 webtpa ppo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 79.46 79.46 webtpa epo "Blood test, thyroid stimulating hormone (TSH)" cpt 84443 81.09 81.09 14.94 14.94 129.74 129.74 108.12 108.12 O 79.46 79.46 webtpa pos Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 31.91 31.91 webtpa ppo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 31.91 31.91 webtpa epo Amylase (enzyme) level cpt 82150 34.19 34.19 3.91 3.91 54.7 54.7 45.58 45.58 O 31.91 31.91 webtpa pos Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 25.23 25.23 webtpa ppo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 25.23 25.23 webtpa epo Syphilis detection test cpt 86592 27.03 27.03 3.8 3.8 43.25 43.25 36.04 36.04 O 25.23 25.23 webtpa pos "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 110.13 110.13 webtpa ppo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 110.13 110.13 webtpa epo "Coagulation function measurement, D-dimer; quantitative" cpt 85379 115.63 115.63 9.05 9.05 132.16 132.16 110.13 110.13 E 110.13 110.13 webtpa pos Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 185.01 185.01 webtpa ppo Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 185.01 185.01 webtpa epo Administration of 1 vaccine cpt 90471 1474.83 1474.83 185.01 185.01 1605.23 1605.23 1337.69 1337.69 O 185.01 185.01 webtpa pos pt education noc individ cpt S9445 69.75 69.75 58.24 58.24 119.57 119.57 99.64 99.64 O 69.75 69.75 webtpa ppo pt education noc individ cpt S9445 69.75 69.75 58.24 58.24 119.57 119.57 99.64 99.64 O 69.75 69.75 webtpa epo pt education noc individ cpt S9445 69.75 69.75 58.24 58.24 119.57 119.57 99.64 99.64 O 69.75 69.75 webtpa pos "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 217.36 217.36 webtpa ppo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 217.36 217.36 webtpa epo "X-ray of foot, minimum of 3 views" cpt 73630 221.81 221.81 20.35 20.35 354.89 354.89 295.74 295.74 O 217.36 217.36 webtpa pos septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 14989.29 14989.29 webtpa ppo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 14989.29 14989.29 webtpa epo septicemia or severe sepsis without mv >96 hours without mcc ms-drg 872 15942.66 15942.66 4743.96 4743.96 25384.62 25384.62 21153.85 21153.85 I 14989.29 14989.29 webtpa pos Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 309.41 309.41 webtpa ppo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 309.41 309.41 webtpa epo Ultrasound of head and neck cpt 76536 331.52 331.52 73.94 73.94 530.42 530.42 442.02 442.02 O 309.41 309.41 webtpa pos "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 322.77 322.77 webtpa ppo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 322.77 322.77 webtpa epo "Testing for presence of drug, read by instrument assisted observation" cpt 80306 345.82 345.82 10.33 10.33 553.32 553.32 461.1 461.1 O 322.77 322.77 webtpa pos General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 292.91 292.91 webtpa ppo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 292.91 292.91 webtpa epo General revCode 300 3043.23 3043.23 34.73 34.73 10533.8 10533.8 8778.17 8778.17 O 292.91 292.91 webtpa pos General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 701.96 701.96 webtpa ppo General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 701.96 701.96 webtpa epo General revCode 320 6718.4 6718.4 701.96 701.96 4716.83 4716.83 3930.69 3930.69 O 701.96 701.96 webtpa pos "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 157.3 157.3 webtpa ppo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 157.3 157.3 webtpa epo "Gonadotropin, luteinizing (reproductive hormone) level" cpt 83002 168.54 168.54 11.16 11.16 269.66 269.66 224.72 224.72 O 157.3 157.3 webtpa pos Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 49183.7 49183.7 webtpa ppo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 49183.7 49183.7 webtpa epo Major joint replacement (Hip/Knee) ms-drg 470 51283.25 51283.25 9155.37 9155.37 77641.55 77641.55 64701.29 64701.29 I 49183.7 49183.7 webtpa pos red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 8768.28 8768.28 webtpa ppo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 8768.28 8768.28 webtpa epo red blood cell disorders with mcc ms-drg 811 15107.34 15107.34 6276.26 6276.26 29647.03 29647.03 24705.86 24705.86 I 8768.28 8768.28 webtpa pos "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 58.66 58.66 webtpa ppo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 58.66 58.66 webtpa epo "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" cpt 85025 59.86 59.86 6.91 6.91 95.77 95.77 79.81 79.81 O 58.66 58.66 webtpa pos Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 246.97 246.97 webtpa ppo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 246.97 246.97 webtpa epo Radiation therapy total body port plan cpt 77321 316.47 316.47 246.97 246.97 403.22 403.22 336.02 336.02 O 246.97 246.97 webtpa pos Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 171.92 171.92 webtpa ppo Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 171.92 171.92 webtpa epo Chemistry revCode 301 3532.41 3532.41 171.92 171.92 11030.75 11030.75 9192.29 9192.29 O 171.92 171.92 webtpa pos "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 65.3 65.3 webtpa ppo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 65.3 65.3 webtpa epo "Gonadotropin, follicle stimulating (reproductive hormone) level" cpt 83001 69.96 69.96 11.2 11.2 111.94 111.94 93.28 93.28 O 65.3 65.3 webtpa pos "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 343.58 343.58 webtpa ppo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 343.58 343.58 webtpa epo "Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" cpt 97110 2994.51 2994.51 343.58 343.58 5002.78 5002.78 4168.98 4168.98 O 343.58 343.58 webtpa pos CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 796.91 796.91 webtpa ppo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 796.91 796.91 webtpa epo CT scan of face cpt 70486 875.18 875.18 81.02 81.02 1366.13 1366.13 1138.44 1138.44 O 796.91 796.91 webtpa pos "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 45.26 45.26 webtpa ppo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 45.26 45.26 webtpa epo "Bacterial colony count, urine" cpt 87086 48.5 48.5 4.86 4.86 77.59 77.59 64.66 64.66 O 45.26 45.26 webtpa pos hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 14050.94 14050.94 webtpa ppo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 14050.94 14050.94 webtpa epo hypertension without mcc ms-drg 305 18810.66 18810.66 3377.11 3377.11 19962.74 19962.74 16635.62 16635.62 I 14050.94 14050.94 webtpa pos "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 18.21 18.21 webtpa ppo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 18.21 18.21 webtpa epo "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" cpt 86003 29.21 29.21 5.22 5.22 42.88 42.88 35.73 35.73 O 18.21 18.21 webtpa pos X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 537.58 537.58 webtpa ppo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 537.58 537.58 webtpa epo X-ray lower and sacral spine including bending views minimum 6 views cpt 72114 575.98 575.98 37.12 37.12 877.68 877.68 731.4 731.4 O 537.58 537.58 webtpa pos "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 192.18 192.18 webtpa ppo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 192.18 192.18 webtpa epo "Ultrasound of one breast, limited" cpt 76642 216.32 216.32 45.12 45.12 329.45 329.45 274.54 274.54 O 192.18 192.18 webtpa pos "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 4856.9 4856.9 webtpa ppo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 4856.9 4856.9 webtpa epo "alcohol, drug abuse or dependence without rehabilitation therapy without mcc" ms-drg 897 5814.25 5814.25 1891.86 1891.86 16430.57 16430.57 13692.14 13692.14 I 4856.9 4856.9 webtpa pos "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 217.36 217.36 webtpa ppo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 217.36 217.36 webtpa epo "X-ray of ankle, minimum of 3 views" cpt 73610 232.89 232.89 21.85 21.85 334.8 334.8 279 279 O 217.36 217.36 webtpa pos "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 66.06 66.06 webtpa ppo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 66.06 66.06 webtpa epo "Detection test by nucleic acid for clostridium difficile, amplified probe technique" cpt 87493 67.41 67.41 13.82 13.82 107.86 107.86 89.88 89.88 O 66.06 66.06 webtpa pos MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1805.42 1805.42 webtpa ppo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1805.42 1805.42 webtpa epo MRI scan of upper spinal canal cpt 72141 1942.19 1942.19 123.29 123.29 3107.5 3107.5 2589.58 2589.58 O 1805.42 1805.42 webtpa pos "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 185.01 185.01 webtpa ppo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 185.01 185.01 webtpa epo "Emergency department visit, moderately severe problem" cpt 99283 702.39 702.39 185.01 185.01 1224.94 1224.94 1020.78 1020.78 O 185.01 185.01 webtpa pos "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 185.01 185.01 webtpa ppo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 185.01 185.01 webtpa epo "Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes" cpt 12011 1652.17 1652.17 185.01 185.01 4586.89 4586.89 3822.41 3822.41 O 185.01 185.01 webtpa pos SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 117.6 117.6 webtpa ppo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 117.6 117.6 webtpa epo SARS-COV-2 COVID-19 AMP PRB cpt 87635 1660.16 1660.16 51.31 51.31 201.6 201.6 168 168 O 117.6 117.6 webtpa pos Minor surgery revCode 361 2031.56 2031.56 2031.56 2031.56 5049.49 5049.49 4207.91 4207.91 O 2031.56 2031.56 webtpa ppo Minor surgery revCode 361 2031.56 2031.56 2031.56 2031.56 5049.49 5049.49 4207.91 4207.91 O 2031.56 2031.56 webtpa epo Minor surgery revCode 361 2031.56 2031.56 2031.56 2031.56 5049.49 5049.49 4207.91 4207.91 O 2031.56 2031.56 webtpa pos percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 102531.45 102531.45 webtpa ppo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 102531.45 102531.45 webtpa epo percutaneous cardiovascular procedures with drug-eluting stent with mcc or 4+ arteries or stents ms-drg 246 102531.45 102531.45 16056.72 16056.72 120967.27 120967.27 100806.06 100806.06 I 102531.45 102531.45 webtpa pos "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 445.64 445.64 webtpa ppo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 445.64 445.64 webtpa epo "X-ray of both hips with pelvis, minimum of 5 views" cpt 73523 445.64 445.64 36.22 36.22 727.58 727.58 606.32 606.32 O 445.64 445.64 webtpa pos ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 208.5 208.5 webtpa ppo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 208.5 208.5 webtpa epo ldct for lung ca screen cpt G0297 312.75 312.75 69.29 69.29 357.43 357.43 297.86 297.86 O 208.5 208.5 webtpa pos General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 13935.82 13935.82 webtpa ppo General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 13935.82 13935.82 webtpa epo General revCode 360 13935.82 13935.82 8642.34 8642.34 28909.84 28909.84 24091.53 24091.53 O 13935.82 13935.82 webtpa pos "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 241.2 241.2 webtpa ppo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 241.2 241.2 webtpa epo "Qualitative or semiquantitative detection test by immunoassay technique for helicobacter pylori in stool, multiple-step method" cpt 87338 246.13 246.13 8.66 8.66 393.8 393.8 328.17 328.17 O 241.2 241.2 webtpa pos "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 309.52 309.52 webtpa ppo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 309.52 309.52 webtpa epo "X-ray of chest, 2 views" cpt 71046 309.52 309.52 17.46 17.46 371.42 371.42 309.52 309.52 E 309.52 309.52 webtpa pos Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 46.45 46.45 webtpa ppo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 46.45 46.45 webtpa epo Cyanocobalamin (vitamin B-12) level cpt 82607 49.76 49.76 9.08 9.08 79.62 79.62 66.35 66.35 O 46.45 46.45 webtpa pos Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 14535.84 14535.84 webtpa ppo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 14535.84 14535.84 webtpa epo Other implants revCode 278 14535.84 14535.84 7453.01 7453.01 66615.74 66615.74 55513.12 55513.12 O 14535.84 14535.84 webtpa pos Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 53.42 53.42 webtpa ppo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 53.42 53.42 webtpa epo Ferritin (blood protein) level cpt 82728 58.67 58.67 12.12 12.12 91.58 91.58 76.32 76.32 O 53.42 53.42 webtpa pos "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 158.79 158.79 webtpa ppo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 158.79 158.79 webtpa epo "Pathology examination of tissue using a microscope, intermediate complexity" cpt 88305 226.84 226.84 26.64 26.64 272.21 272.21 226.84 226.84 O 158.79 158.79 webtpa pos MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa ppo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa epo MRI scan of lower spinal canal cpt 72148 1942.19 1942.19 123.59 123.59 3107.5 3107.5 2589.58 2589.58 O 1812.71 1812.71 webtpa pos "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 133.56 133.56 webtpa ppo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 133.56 133.56 webtpa epo "Pathology examination of tissue using a microscope, moderately low complexity" cpt 88304 195.57 195.57 24.37 24.37 228.96 228.96 190.8 190.8 O 133.56 133.56 webtpa pos "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 446.68 446.68 webtpa ppo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 446.68 446.68 webtpa epo "Ultrasound of abdomen, limited" cpt 76705 478.59 478.59 52.09 52.09 765.74 765.74 638.12 638.12 O 446.68 446.68 webtpa pos Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 500.11 500.11 webtpa ppo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 500.11 500.11 webtpa epo Ultrasound pelvis through vagina cpt 76830 535.83 535.83 73.68 73.68 857.33 857.33 714.44 714.44 O 500.11 500.11 webtpa pos als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2018.99 2018.99 webtpa ppo als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2018.99 2018.99 webtpa epo als 1 cpt A0426 2862 2862 763.59 763.59 3265.2 3265.2 2721 2721 O 2018.99 2018.99 webtpa pos "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 95.27 95.27 webtpa ppo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 95.27 95.27 webtpa epo "Blood test, lipids (cholesterol and triglycerides)" cpt 80061 102.07 102.07 8.06 8.06 127.4 127.4 106.17 106.17 O 95.27 95.27 webtpa pos cervical spinal fusion with mcc ms-drg 471 46211.54 46211.54 27832.43 27832.43 101079.62 101079.62 84233.02 84233.02 I 46211.54 46211.54 webtpa ppo cervical spinal fusion with mcc ms-drg 471 46211.54 46211.54 27832.43 27832.43 101079.62 101079.62 84233.02 84233.02 I 46211.54 46211.54 webtpa epo cervical spinal fusion with mcc ms-drg 471 46211.54 46211.54 27832.43 27832.43 101079.62 101079.62 84233.02 84233.02 I 46211.54 46211.54 webtpa pos "Estrogen analysis, fractionated" cpt 82671 274.54 274.54 28.73 28.73 457.32 457.32 381.1 381.1 O 274.54 274.54 webtpa ppo "Estrogen analysis, fractionated" cpt 82671 274.54 274.54 28.73 28.73 457.32 457.32 381.1 381.1 O 274.54 274.54 webtpa epo "Estrogen analysis, fractionated" cpt 82671 274.54 274.54 28.73 28.73 457.32 457.32 381.1 381.1 O 274.54 274.54 webtpa pos "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 7.27 7.27 webtpa ppo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 7.27 7.27 webtpa epo "Blood count, hemoglobin" cpt 85018 31.01 31.01 2.11 2.11 46.8 46.8 39 39 O 7.27 7.27 webtpa pos Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 1846.98 1846.98 webtpa ppo Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 1846.98 1846.98 webtpa epo Body scan revCode 352 2997.13 2997.13 1846.98 1846.98 12378.82 12378.82 10315.68 10315.68 O 1846.98 1846.98 webtpa pos non-extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 987 39092.28 39092.28 19983.77 19983.77 81264.44 81264.44 67720.37 67720.37 I 39092.28 39092.28 webtpa ppo non-extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 987 39092.28 39092.28 19983.77 19983.77 81264.44 81264.44 67720.37 67720.37 I 39092.28 39092.28 webtpa epo non-extensive o.r. procedures unrelated to principal diagnosis with mcc ms-drg 987 39092.28 39092.28 19983.77 19983.77 81264.44 81264.44 67720.37 67720.37 I 39092.28 39092.28 webtpa pos percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 64931.69 64931.69 webtpa ppo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 64931.69 64931.69 webtpa epo percutaneous cardiovascular procedures with drug-eluting stent without mcc ms-drg 247 64931.69 64931.69 8541.69 8541.69 88718.5 88718.5 73932.08 73932.08 I 64931.69 64931.69 webtpa pos Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 170.66 170.66 webtpa ppo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 170.66 170.66 webtpa epo Diagnostic mammography of one breast cpt 77065 197.59 197.59 78.49 78.49 292.56 292.56 243.8 243.8 O 170.66 170.66 webtpa pos "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 92.82 92.82 webtpa ppo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 92.82 92.82 webtpa epo "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" cpt 87491 99.45 99.45 21.14 21.14 159.12 159.12 132.6 132.6 O 92.82 92.82 webtpa pos Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 493.95 493.95 webtpa ppo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 493.95 493.95 webtpa epo Ultrasound behind abdominal cavity cpt 76770 493.95 493.95 64.36 64.36 806.45 806.45 672.04 672.04 O 493.95 493.95 webtpa pos Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 40.96 40.96 webtpa ppo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 40.96 40.96 webtpa epo Fungal culture (mold or yeast) cpt 87102 43.88 43.88 7.48 7.48 70.21 70.21 58.51 58.51 O 40.96 40.96 webtpa pos Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 1442.37 1442.37 webtpa ppo Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 1442.37 1442.37 webtpa epo Head scan revCode 351 2909.63 2909.63 1442.37 1442.37 14535.66 14535.66 12113.05 12113.05 O 1442.37 1442.37 webtpa pos "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 43 43 webtpa ppo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 43 43 webtpa epo "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" cpt 80051 43 43 6.34 6.34 73.72 73.72 61.43 61.43 O 43 43 webtpa pos ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 62.48 62.48 webtpa ppo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 62.48 62.48 webtpa epo ANTIBODY SARS-COV-2 COVID-19 cpt 86769 4492.48 4492.48 62.48 62.48 9187.27 9187.27 7656.06 7656.06 O 62.48 62.48 webtpa pos "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 224.08 224.08 webtpa ppo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 224.08 224.08 webtpa epo "X-ray of knee, 4 or more views" cpt 73564 240.09 240.09 27.24 27.24 362.4 362.4 302 302 O 224.08 224.08 webtpa pos "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 594.34 594.34 webtpa ppo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 594.34 594.34 webtpa epo "Emergency department visit, problem of high severity" cpt 99284 2959.28 2959.28 594.34 594.34 4740.01 4740.01 3950.01 3950.01 O 594.34 594.34 webtpa pos other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 17445.39 17445.39 webtpa ppo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 17445.39 17445.39 webtpa epo other kidney and urinary tract diagnoses with mcc ms-drg 698 18781.88 18781.88 2628.54 2628.54 33701.81 33701.81 28084.84 28084.84 I 17445.39 17445.39 webtpa pos kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 13701.94 13701.94 webtpa ppo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 13701.94 13701.94 webtpa epo kidney and urinary tract infections without mcc ms-drg 690 13701.94 13701.94 2894.21 2894.21 18878.44 18878.44 15732.03 15732.03 I 13701.94 13701.94 webtpa pos laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 23726.76 23726.76 webtpa ppo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 23726.76 23726.76 webtpa epo laparoscopic cholecystectomy without c.d.e. without cc/mcc ms-drg 419 23726.76 23726.76 5653.63 5653.63 40773.58 40773.58 33977.98 33977.98 I 23726.76 23726.76 webtpa pos "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 141.02 141.02 webtpa ppo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 141.02 141.02 webtpa epo "X-ray of hip with pelvis, 2-3 views" cpt 73502 141.02 141.02 28.44 28.44 217.2 217.2 181 181 O 141.02 141.02 webtpa pos Cardiac rehabilitation revCode 943 689.04 689.04 689.04 689.04 1124.93 1124.93 937.44 937.44 O 689.04 689.04 webtpa ppo Cardiac rehabilitation revCode 943 689.04 689.04 689.04 689.04 1124.93 1124.93 937.44 937.44 O 689.04 689.04 webtpa epo Cardiac rehabilitation revCode 943 689.04 689.04 689.04 689.04 1124.93 1124.93 937.44 937.44 O 689.04 689.04 webtpa pos Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 238.18 238.18 webtpa ppo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 238.18 238.18 webtpa epo Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus cpt 76801 261.58 261.58 61.35 61.35 408.31 408.31 340.26 340.26 O 238.18 238.18 webtpa pos Education/training revCode 942 117.93 117.93 117.93 117.93 186.34 186.34 155.28 155.28 O 117.93 117.93 webtpa ppo Education/training revCode 942 117.93 117.93 117.93 117.93 186.34 186.34 155.28 155.28 O 117.93 117.93 webtpa epo Education/training revCode 942 117.93 117.93 117.93 117.93 186.34 186.34 155.28 155.28 O 117.93 117.93 webtpa pos Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report cpt 93010 24.15 24.15 6.96 6.96 39.43 39.43 32.86 32.86 O 23 23 webtpa medicare advantage ppo Visit charge revCode 421 2253.92 2253.92 92.46 92.46 4980 4980 4150 4150 O 1420.17 1420.17 workers comp workers comp