/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