/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 r