PAYER_NAME,LOCATION,BILL_TYPE,PT_SUMMARY,PRIMARY_CODE,PRIMARY_CODE_DESCRIPTION,GROSS_CHARGES,CASH_PRICE_INPATIENT,CASH_PRICE_OUTPATIENT,PAYER_NEGOTIATED_RATE,MIN_NEGOTIATED_RATE,MAX_NEGOTIATED_RATE,,,FULL CHARGEMASTER ->,,,DESCRIPTION,CPT,REVCD,NDC,PRICE,INPT CASH PRICE,OUTPT CASH PRICE
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,92.7,52.53,206.9,,,,,,Stool for Occult Blood POC,82272,0521,,,,
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.03,22.37,41.75,,,,,,Blood Glucose Monitoring POC,82947,0300,,50.8,38.1,38.1
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,67.53,39.55,134.08,,,,,,Urine Pregnancy Test POC,81025,0521,,,,
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,36.7,31.68,51.15,,,,,,XR Chest 2 Views,71046,0320,,271.3,203.475,203.475
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,67.86,45.48,91.29,,,,,,Fetal Non-Stress Test,,,,,,
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,124.75,114.76,176.55,,,,,,Hearing Screen POC,,,,,,
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,68.47,59.99,274.04,,,,,,PPD Administration (TB Screen) POC,86580,0521,,,,
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,Clinic,Institutional,Outpatient,99199,"Unlisted procedure, service, or report [HCPCS 99199]",233.1,174.83,174.83,8028.2,167.61,8028.2,,,,,,Rapid Strep POC,87880,0521,,,,
ACTUARIAL MANAGEMENT RESOURCES - Commercial-PPO,Hospital,Institutional,Outpatient,99199,"Unlisted procedure, service, or report [HCPCS 99199]",233.1,174.83,174.83,8028.2,167.61,8028.2,,,,,,Urinalysis Dipstick POC,81002,0521,,,,
AETNA - Commercial-POS,,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,69.53,45.48,91.29,,,,,,Office Visit No Charge,,0521,,,,
AETNA - Commercial-POS,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,237.73,35.11,337.46,,,,,,BD Bone Density DEXA App Skeleton,77081,0409,,212.4,159.3,159.3
AETNA - Commercial-POS,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,100,70.45,319.43,,,,,,BD Bone Density DEXA Axial Skeleton,77080,0409,,286.1,214.575,214.575
AETNA - Commercial-POS,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,107.28,107.28,315.01,,,,,,CT Abdomen w/ + w/o Contrast,74170,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,76.88,61.63,100.1,,,,,,CT Abdomen w/ Contrast,74160,0352,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Clinic,Professional,Outpatient,57454,Cervix biopsy and scraping with endoscope [HCPCS 57454],807.1,605.33,605.33,196.34,196.34,248.58,,,,,,CT Abdomen w/o Contrast,74150,0352,,"1,267.9",950.925,950.925
AETNA - Commercial-POS,Clinic,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,27.55,22.99,68.3,,,,,,CT Angio Abdomen Aorta + Iliofemoral,75635,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,15.1,12.82,82,,,,,,CT Angio Abdomen,74175,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,15.07,1.28,46.3,,,,,,CT Angio Chest,71275,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,CT Angio Brain/Head,70496,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,97169,Athletic training evaluation (typically 15 minutes) [HCPCS 97169],49.7,37.28,37.28,42.13,39.17,42.13,,,,,,CT Angio Lower Extremity Left,73706,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,105.91,91.42,145.6,,,,,,CT Angio Lower Extremity Right,73706,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,140.39,140.39,202.54,,,,,,CT Angio Neck,70498,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,44.56,13.55,72.8,,,,,,CT Angio Pelvis,72191,0352,,"1,345.1",1008.825,1008.825
AETNA - Commercial-POS,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,76.51,62.38,245.75,,,,,,CT Brain/Head w/ + w/o Contrast,70470,0351,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,18.68,14.35,372.57,,,,,,CT Brain/Head w/ Contrast,70460,0351,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,CT Brain/Head w/o Contrast,70450,0351,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.37,1.1,17.76,,,,,,CT Lower Extremity w/ Contrast Left,73701,0352,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,CT Lower Extremity w/ Contrast Right,73701,0352,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],6338.06,4753.55,4753.55,0,1272.13,4240.7,,,,,,CT Lower Extremity w/+w/o Contrast Left,73702,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],339.6,254.7,254.7,255.16,81.5,323.4,,,,,,CT Lower Extremity w/+w/o Contrast Right,73702,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,688.76,137.3,1347.57,,,,,,CT Lower Extremity w/o Contrast Left,73700,0352,,694.6,520.95,520.95
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,70460,"Head or brain CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 70460]",1319.8,989.85,989.85,1041.32,1041.32,1049.9,,,,,,CT Lower Extremity w/o Contrast Right,73700,0352,,694.6,520.95,520.95
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,70496,CTA scan of head blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70496],1345.1,1008.83,1008.83,589.26,563.64,889.41,,,,,,CT Maxillofacial w/ + w/o Contrast,70488,0351,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,70498,CTA scan of neck blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70498],1345.1,1008.83,1008.83,294.63,294.63,889.41,,,,,,CT Maxillofacial w/ Contrast,70487,0351,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,197.57,20.71,250.4,,,,,,CT Maxillofacial w/o Contrast,70486,0351,,"1,313.2",984.9,984.9
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,214.06,28.74,271.3,,,,,,CT Orbits Sella w/ + w/o Contrast,70482,0351,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,177.53,69.84,223.7,,,,,,CT Orbits Sella w/ Contrast,70481,0351,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,1028.22,166.13,1107.72,,,,,,CT Orbits Sella w/o Contrast,70480,0351,,"1,313.2",984.9,984.9
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,825.61,350.85,825.61,,,,,,CT Pelvis w/ + w/o Contrast,72194,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,169,30.08,220.5,,,,,,CT Pelvis w/ Contrast,72193,0352,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],225,168.75,168.75,177.53,94.25,225,,,,,,CT Pelvis w/o Contrast,72192,0352,,"1,221.6",916.2,916.2
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,169,94.25,214.2,,,,,,CT Sinus w/o Contrast,70486,0351,,"1,005.5",754.125,754.125
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,177.53,37.7,213.75,,,,,,CT Neck Soft Tissue w/ + w/o Contrast,70492,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1964.22,180.22,3324.06,,,,,,CT Neck Soft Tissue w/ Contrast,70491,0352,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1980.78,561.23,2500,,,,,,CT Neck Soft Tissue w/o Contrast,70490,0352,,"1,156.6",867.45,867.45
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,74300,X-ray of bile and/or pancreatic ducts during surgery including radiological supervision of procedure and interpretation of results [HCPCS 74300],88.2,66.15,66.15,0,58.91,58.91,,,,,,CT Spine Cervical w/ + w/o Contrast,72127,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,589.78,110.94,589.78,,,,,,CT Spine Cervical w/ Contrast,72126,0352,,"1,431.1",1073.325,1073.325
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,242.78,62.12,274.64,,,,,,CT Spine Cervical w/o Contrast,72125,0352,,"1,303.2",977.4,977.4
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,352.13,137.3,401.67,,,,,,CT Spine Lumbar w/ + w/o Contrast,72133,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,504.57,166.13,529.81,,,,,,CT Spine Lumbar w/ Contrast,72132,0352,,"1,479.6",1109.7,1109.7
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,58.93,23.61,157.86,,,,,,CT Spine Lumbar w/o Contrast,72131,0352,,"1,323",992.25,992.25
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,130.41,89.59,349.41,,,,,,CT Spine Thoracic w/ + w/o Contrast,72130,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,0,8.49,161,,,,,,CT Spine Thoracic w/ Contrast,72129,0352,,"1,479.6",1109.7,1109.7
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,194.09,8.87,355.2,,,,,,CT Spine Thoracic w/o Contrast,72128,0352,,"1,323",992.25,992.25
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,117.48,11.25,148.9,,,,,,CT Chest w/ + w/o Contrast,71270,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,234.89,14.4,297.7,,,,,,CT Chest w/ Contrast,71260,0352,,"1,412.4",1059.3,1059.3
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,9.42,73.71,,,,,,CT Chest w/o Contrast,71250,0352,,"1,323",992.25,992.25
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,0,9.63,285.09,,,,,,CT Upper Extremity w/ Contrast Left,73201,0352,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,60.12,2.66,76.2,,,,,,CT Upper Extremity w/ Contrast Right,73201,0352,,"1,319.8",989.85,989.85
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,81005,Lab analysis of urine specimen without immunoassays [HCPCS 81005],111.4,83.55,83.55,83.71,2.17,83.71,,,,,,CT Upper Extremity w/+w/o Contrast Left,73202,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,64.38,6.2,81.6,,,,,,CT Upper Extremity w/+w/o Contrast Right,73202,0352,,"1,572.2",1179.15,1179.15
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,20.91,2.31,20.91,,,,,,CT Upper Extremity w/o Contrast Left,73200,0352,,"1,232.6",924.45,924.45
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,75.74,5.44,96,,,,,,CT Upper Extremity w/o Contrast Right,73200,0352,,"1,232.6",924.45,924.45
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,38.5,16.18,45.86,,,,,,MRA Abdomen w/ Contrast,74185,0610,,"1,362.7",1022.025,1022.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,76.61,4.35,81.23,,,,,,MRA Abdomen w/o Contrast,74185,0610,,"1,362.7",1022.025,1022.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,367.12,32.34,465.3,,,,,,MRA Chest w/ Contrast,71555,0610,,"1,341.8",1006.35,1006.35
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],480.7,360.53,360.53,180.6,28.4,180.6,,,,,,MRA Chest w/o Contrast,71555,0610,,"1,341.8",1006.35,1006.35
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,165.69,16.1,220.5,,,,,,MRA Brain/Head w/ + w/o Contrast,70546,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,91.45,8.16,104.31,,,,,,MRA Brain/Head w/ Contrast,70545,0610,,"1,227.2",920.4,920.4
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,347.95,11.58,453.2,,,,,,MRA Brain/Head w/o Contrast,70544,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,153.14,9.72,190.22,,,,,,MRA Lower Extremity w/ Contrast Left,73725,0610,,"1,351.7",1013.775,1013.775
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,83.56,5,105.9,,,,,,MRA Lower Extremity w/ Contrast Right,73725,0610,,"1,351.7",1013.775,1013.775
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,33.49,5.63,72.8,,,,,,MRA Lower Extremity w/o Contrast Left,73725,0610,,"1,351.7",1013.775,1013.775
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83835,Lab analysis to measure the metanephrines level in urine specimen [HCPCS 83835],409.1,306.83,306.83,287.91,16.94,287.91,,,,,,MRA Lower Extremity w/o Contrast Right,73725,0610,,"1,351.7",1013.775,1013.775
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,222.73,32.98,268.8,,,,,,MRA Neck w/ + w/o Contrast,70549,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,84030,"Lab analysis to measure the phenylalanine, PKU (amino acid) level in blood specimen [HCPCS 84030]",102.6,76.95,76.95,77.09,4.62,77.09,,,,,,MRA Neck w/ Contrast,70548,0610,,"1,227.2",920.4,920.4
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,84154,Lab analysis to measure the amount of free PSA (prostate specific antigen) in serum specimen [HCPCS 84154],222.7,167.03,167.03,97.57,93.32,135.4,,,,,,MRA Neck w/o Contrast,70547,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,46.16,3.73,46.16,,,,,,MRA Pelvis w/ Contrast,72198,0610,,"1,356.1",1017.075,1017.075
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,102.65,7.58,134.6,,,,,,MRA Pelvis w/o Contrast,72198,0610,,"1,356.1",1017.075,1017.075
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,107.07,14.11,134.34,,,,,,MRA Upper Extremity w/ Contrast Left,73225,0610,,"1,403.6",1052.7,1052.7
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,64.95,9.87,141.2,,,,,,MRA Upper Extremity w/ Contrast Right,73225,0610,,"1,403.6",1052.7,1052.7
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,48.76,7.65,55.26,,,,,,MRA Upper Extremity w/o Contrast Left,73225,0610,,"1,403.6",1052.7,1052.7
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,69.59,6,88.2,,,,,,MRA Upper Extremity w/o Contrast Right,73225,0610,,"1,403.6",1052.7,1052.7
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,54.91,3.6,69.6,,,,,,MRI Abdomen w/ + w/o Contrast,74183,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,53.89,2.7,54.33,,,,,,MRI Abdomen w/ Contrast,74182,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,54.91,6.03,69.6,,,,,,MRI Abdomen w/o Contrast,74181,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,207.98,12.29,258.33,,,,,,MRI Ankle w/ + w/o Contrast Left,73723,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86039,Lab analysis to screen for autoimmune disorders by titer [HCPCS 86039],91.6,68.7,68.7,72.27,18.5,73.28,,,,,,MRI Ankle w/ + w/o Contrast Right,73723,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,60.12,5.26,76.2,,,,,,MRI Ankle w/ Contrast Left,73722,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,111.41,12.2,112.96,,,,,,MRI Ankle w/ Contrast Right,73722,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,178.39,18.22,199.4,,,,,,MRI Ankle w/o Contrast Left,73721,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,184.47,12.25,187.04,,,,,,MRI Ankle w/o Contrast Right,73721,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,95.71,14.79,121.3,,,,,,MRI Brain w/ + w/o Contrast,70553,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,147.07,5.76,186.4,,,,,,MRI Brain w/ Contrast,70552,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,74.01,16.62,74.01,,,,,,MRI Brain w/o Contrast,70551,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,111.41,9.2,112.32,,,,,,MRI Chest w/ + w/o Contrast,71552,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,74.56,7.24,496.86,,,,,,MRI Chest w/ Contrast,71551,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,75.43,6.79,100.4,,,,,,MRI Chest w/o Contrast,71550,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,85.29,2.84,108.1,,,,,,MRI Elbow w/ + w/o Contrast Left,73223,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,19.57,6.8,52.43,,,,,,MRI Elbow w/ + w/o Contrast Right,73223,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,129.24,7.27,172,,,,,,MRI Elbow w/ Contrast Left,73222,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,122.69,8.17,155.5,,,,,,MRI Elbow w/ Contrast Right,73222,0610,,"3,040.7",2280.525,2280.525
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,116.85,11.68,116.85,,,,,,MRI Elbow w/o Contrast Left,73221,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,0,37.79,110.3,,,,,,MRI Elbow w/o Contrast Right,73221,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,155.5,29.48,155.5,,,,,,MRI Face Neck Orbit w/ + w/o Contrast,70543,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,155.5,29.48,155.5,,,,,,MRI Face Neck Orbit w/ Contrast,70542,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,130.5,45.82,378.9,,,,,,MRI Face Neck Orbit w/o Contrast,70540,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,82.85,29.48,105,,,,,,MRI Hip w/ + w/o Contrast Left,73723,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,0,13.86,24.19,,,,,,MRI Hip w/ + w/o Contrast Right,73723,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,96.65,6.15,4344.87,,,,,,MRI Hip w/ Contrast Left,73722,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,536.05,166.13,1092.27,,,,,,MRI Hip w/ Contrast Right,73722,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,MRI Hip w/o Contrast Left,73721,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,76.61,16.26,2475.42,,,,,,MRI Hip w/o Contrast Right,73721,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,352.37,68.61,524.17,,,,,,MRI Knee w/ + w/o Contrast Left,73723,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,61.86,4.51,1156.79,,,,,,MRI Knee w/ + w/o Contrast Right,73723,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,157.48,29.4,2785.69,,,,,,MRI Knee w/ Contrast Left,73722,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,31.32,12.56,48.28,,,,,,MRI Knee w/ Contrast Right,73722,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,0,13.42,41.31,,,,,,MRI Knee w/o Contrast Left,73721,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,68.36,40.84,136.8,,,,,,MRI Knee w/o Contrast Right,73721,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],101.5,76.13,76.13,80.08,37.78,80.08,,,,,,MRI LE Non Joint w/ + w/o Contrast Lt,73720,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,66.12,23.51,98.36,,,,,,MRI LE Non Joint w/ + w/o Contrast Rt,73720,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,287.99,140.59,428.4,,,,,,MRI LE Non Joint w/ Contrast Lt,73719,0610,,"1,227.2",920.4,920.4
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],247,185.25,185.25,0,103.49,144.41,,,,,,MRI LE Non Joint w/ Contrast Rt,73719,0610,,"1,227.2",920.4,920.4
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,103.6,40.84,154.11,,,,,,MRI LE Non Joint w/o Contrast Lt,73718,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,193.15,39.1,434.06,,,,,,MRI LE Non Joint w/o Contrast Rt,73718,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,303.69,61.48,2109.82,,,,,,MRI Pelvis w/ + w/o Contrast,72197,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,449.81,50,3116.59,,,,,,MRI Pelvis w/ Contrast,72196,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,738.58,62.92,1098.7,,,,,,MRI Pelvis w/o Contrast,72195,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,8.76,3.22,2266.54,,,,,,MRI Shoulder w/ + w/o Contrast Left,73223,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,9.86,5.5,14.67,,,,,,MRI Shoulder w/ + w/o Contrast Right,73223,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,4.93,0.68,2868.2,,,,,,MRI Shoulder w/ Contrast Left,73222,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,4.93,0.11,332.88,,,,,,MRI Shoulder w/ Contrast Right,73222,0610,,"3,041.9",2281.425,2281.425
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J1610,Glucagon hydrochloride/1 mg [HCPCS J1610],409.2,306.9,306.9,0,180.05,273.3,,,,,,MRI Shoulder w/o Contrast Left,73221,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,19.73,7.8,30.4,,,,,,MRI Shoulder w/o Contrast Right,73221,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,0,5.5,14.67,,,,,,MRI Spine Cervical w/ + w/o Contrast,72156,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,0,3.15,30.39,,,,,,MRI Spine Cervical w/ Contrast,72142,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,19.73,11,29.34,,,,,,MRI Spine Cervical w/o Contrast,72141,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,9.87,0.95,3583.7,,,,,,MRI Spine Lumbar w/ + w/o Contrast,72158,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0,0.55,29.34,,,,,,MRI Spine Lumbar w/ Contrast,72149,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,13.38,5.49,347.63,,,,,,MRI Spine Lumbar w/o Contrast,72148,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,0,0.02,4433.9,,,,,,MRI Spine Thoracic w/ + w/o Contrast,72157,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Hospital,Institutional,Outpatient,S0171,Bumetanide 0.5 mg [HCPCS S0171],12.5,9.38,9.38,5.75,5.75,9.6,,,,,,MRI Spine Thoracic w/ Contrast,72147,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,1961,Anesthesia provided during cesarean delivery [HCPCS 01961],139,104.25,104.25,27.52,5.74,329.73,,,,,,MRI Spine Thoracic w/o Contrast,72146,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],7445.3,5583.98,5583.98,300.13,127.52,393.81,,,,,,MRI TMJ,70336,0610,,"1,046.4",784.8,784.8
AETNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,27.55,22.99,68.3,,,,,,MRI UE Non Joint w/ + w/o Contrast Lt,73220,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,138.2,138.2,1470.79,,,,,,MRI UE Non Joint w/ + w/o Contrast Rt,73220,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,72.6,59.99,274.04,,,,,,MRI UE Non Joint w/ Contrast Lt,73219,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,95.59,77,101.03,,,,,,MRI UE Non Joint w/ Contrast Rt,73219,0610,,"1,974.7",1481.025,1481.025
AETNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,42.06,38.82,44.36,,,,,,MRI UE Non Joint w/o Contrast Lt,73218,0610,,"1,046.4",784.8,784.8
"FOX EVERETT, INC. - Commercial-Indemnity",Hospital,Institutional,Outpatient,300,Peripheral vascular disorders with complications,21336.11,16002.08,16002.08,0,174.72,174.72,,,,,,MRI UE Non Joint w/o Contrast Rt,73218,0610,,"1,046.4",784.8,784.8
"FOX EVERETT, INC. - Commercial-Indemnity",Hospital,Institutional,Outpatient,352,Inguinal & femoral hernia procedures without complications,9486.13,7114.6,7114.6,0,1931,1931,,,,,,MRI Wrist w/ + w/o Contrast Left,73223,0610,,"1,974.7",1481.025,1481.025
FRIDAY HEALTH PLANS - Commercial-HMO,,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,110.56,52.38,170.1,,,,,,MRI Wrist w/ + w/o Contrast Right,73223,0610,,"1,974.7",1481.025,1481.025
FRIDAY HEALTH PLANS - Commercial-HMO,,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,134.48,52.53,206.9,,,,,,MRI Wrist w/ Contrast Left,73222,0610,,"3,041.9",2281.425,2281.425
FRINGE BENEFIT GROUP - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,19.9,2.07,19.9,,,,,,MRI Wrist w/ Contrast Right,73222,0610,,"3,040.7",2280.525,2280.525
FRINGE BENEFIT GROUP - Commercial-PPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,111.4,45.56,141.93,,,,,,MRI Wrist w/o Contrast Left,73221,0610,,"1,046.4",784.8,784.8
FRINGE BENEFIT GROUP - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,78.9,62.38,245.75,,,,,,MRI Wrist w/o Contrast Right,73221,0610,,"1,046.4",784.8,784.8
"GILSBAR, L.L.C. - Commercial-Indemnity",,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,US Abdomen Complete,76700,0402,,653.9,490.425,490.425
"GILSBAR, L.L.C. - Commercial-Indemnity",,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,69.3,13.55,72.8,,,,,,US Abdomen Limited,76705,0402,,468.7,351.525,351.525
"GILSBAR, L.L.C. - Commercial-Indemnity",,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,26.3,5.44,26.3,,,,,,US Art/Vein Abd/Pelvis/Scrotal Complete,93975,0402,,635.1,476.325,476.325
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,44.1,1.28,46.3,,,,,,US Art/Vein Abd/Pelvis/Scrotal Limited,93976,0921,,649.5,487.125,487.125
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,US Carotid Duplex Bilateral,93880,0921,,713.4,535.05,535.05
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,89.65,45.56,141.93,,,,,,US Chest,76604,0402,,363.9,272.925,272.925
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,145.6,91.42,145.6,,,,,,US Fetal Biophysical Profile w/o N-Str,76819,0402,,517.2,387.9,387.9
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,US Intraoperative,76998,0402,,653.9,490.425,490.425
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,US Head/Neck Soft Tissue,76536,0402,,747.5,560.625,560.625
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,US Kidney Transplant w/ Doppler,76776,0402,,309.9,232.425,232.425
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,US Lower Ext Arterial Duplex Bilateral,93925,0921,,"1,018.8",764.1,764.1
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.2,1.1,17.76,,,,,,US Lower Ext Arterial Duplex Left,93926,0921,,713.4,535.05,535.05
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,18.9,2.44,580.94,,,,,,US Lower Ext Arterial Duplex Right,93926,0921,,713.4,535.05,535.05
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,104.31,8.16,104.31,,,,,,US Lower Ext Venous Duplex Bilateral,93970,0921,,"1,427.8",1070.85,1070.85
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,122.13,14.11,134.34,,,,,,US Lower Ext Venous Duplex Left,93971,0921,,713.4,535.05,535.05
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,94.54,8.17,155.5,,,,,,US Lower Ext Venous Duplex Right,93971,0921,,713.4,535.05,535.05
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,67.06,37.79,110.3,,,,,,US OB Greater Than 14 Weeks,76805,0402,,653.9,490.425,490.425
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,100.56,45.82,378.9,,,,,,US OB Follow Up,76816,0402,,357.3,267.975,267.975
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,63.84,29.48,105,,,,,,US OB Limited,76815,0402,,357.3,267.975,267.975
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,47.67,4.51,1156.79,,,,,,US OB Nuchal Measure 1st Trimester,76813,0402,,653.9,490.425,490.425
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,US OB Transvaginal,76817,0402,,747.5,560.625,560.625
GOLDEN RULE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],31.47,23.6,23.6,19.14,15.1,23.42,,,,,,US Retroperitoneal Complete,76770,0402,,653.9,490.425,490.425
GOLDEN RULE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,US Retroperitoneal Limited,76775,0402,,580,435,435
GPMLIFE - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,240.44,35.11,337.46,,,,,,US Scrotum (Contents) w/ Doppler if ind,76870,0402,,468.7,351.525,351.525
GPMLIFE - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,300.05,70.45,319.43,,,,,,US Transvaginal Non-OB,76830,0402,,671.5,503.625,503.625
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,58.9,35.11,337.46,,,,,,US Upper Ext Arterial Duplex Bilateral,93930,0921,,"1,021",765.75,765.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,85.68,70.45,319.43,,,,,,US Upper Ext Arterial Duplex Left,93931,0921,,680.3,510.225,510.225
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.82,2.07,19.9,,,,,,US Upper Ext Arterial Duplex Right,93931,0921,,680.3,510.225,510.225
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.66,5.3,61.31,,,,,,US Upper Ext Venous Duplex Bilateral,93970,0921,,680.3,510.225,510.225
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,12.82,12.82,82,,,,,,US Upper Ext Venous Duplex Left,93971,0921,,680.3,510.225,510.225
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,12.82,1.28,46.3,,,,,,US Upper Ext Venous Duplex Right,93971,0921,,713.4,535.05,535.05
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,19.7,15.77,25,,,,,,XR AC Joints Bilateral,73050,0320,,,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,169.1,85.05,170.1,,,,,,XR Abdomen Series + Chest 1 View,74022,0320,,377.1,282.825,282.825
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,XR Ankle 2 Views Left,73600,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,90.18,45.56,141.93,,,,,,XR Ankle 2 Views Right,73600,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,109.78,91.42,145.6,,,,,,XR Ankle Complete 3+ Views Left,73610,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,176.93,140.39,202.54,,,,,,XR Ankle Complete 3+ Views Right,73610,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],281.2,210.9,210.9,211.1,185.38,251.35,,,,,,XR Bone Age Studies,77072,0320,,452.1,339.075,339.075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,44.01,13.55,72.8,,,,,,XR Osseous Survey Complete,77075,0320,,986.8,740.1,740.1
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,73.59,62.38,245.75,,,,,,XR Osseous Survey Infant,77076,0320,,715.6,536.7,536.7
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,109.25,70,166.6,,,,,,XR Osseous Survey Limited,77074,0320,,936.1,702.075,702.075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,147.2,147.2,226.48,,,,,,XR Calcaneous Left,73650,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,XR Calcaneous Right,73650,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.95,14.35,372.57,,,,,,XR Chest 2 Views w/ Apical Lordotic,71047,0320,,270.2,202.65,202.65
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,XR Chest Decubitus,71047,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0,0.08,6.58,,,,,,XR Chest 4+ Views,71048,0320,,447.7,335.775,335.775
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,22.36,5.44,26.3,,,,,,XR Cholangiogram in OR,74300,0320,,88.2,66.15,66.15
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,106.25,55,125,,,,,,XR Clavicle Left,73700,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,106.25,55,166.67,,,,,,XR Clavicle Right,73000,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.44,2.44,580.94,,,,,,XR Elbow 2 Views Left,73070,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],4243.39,3182.54,3182.54,2812.48,246.83,3309.99,,,,,,XR Elbow 2 Views Right,73070,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,91.04,32.67,218.78,,,,,,XR Elbow Complete 3+ Views Left,73080,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,70360,Neck x-ray to examine soft tissue for any obstructions and/or foreign bodies within the throat or neck [HCPCS 70360],225,168.75,168.75,182.07,94.25,182.07,,,,,,XR Elbow Complete 3+ Views Right,73080,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,1272.71,137.3,1347.57,,,,,,XR Facial Bones < 3 Views,70140,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,202.64,20.71,250.4,,,,,,XR Facial Bones 3+ Views,70150,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,1200.54,272.21,1200.54,,,,,,XR Foot 2 Views Left,73620,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,1107.72,166.13,1107.72,,,,,,XR Foot 2 Views Right,73620,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,191.25,94.25,222.4,,,,,,XR Foot Complete 3+ Views Left,73630,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],225,168.75,168.75,191.25,27.4,191.25,,,,,,XR Foot Complete 3+ Views Right,73630,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,191.25,25.73,191.25,,,,,,XR Forearm 2 Views Left,73090,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,182.07,33.08,182.07,,,,,,XR Forearm 2 Views Right,73090,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,191.25,94.25,191.25,,,,,,XR Foreign Body Localization Eye,70030,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,191.25,94.25,214.2,,,,,,XR Foreign Body Localization Child 1 Vw,76010,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,191.25,94.25,191.25,,,,,,XR Hand 2 Views Left,73120,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,191.25,37.7,213.75,,,,,,XR Hand 2 Views Right,73120,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,2116.08,180.22,3324.06,,,,,,XR Hand Complete 3+ Views Left,73130,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,2133.92,561.23,2500,,,,,,XR Hand Complete 3+ Views Right,73130,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,529.3,166.13,529.3,,,,,,XR Hip 1 View Left,73501,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,555.81,107.93,965.26,,,,,,XR Hip 1 View Right,73501,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,529.3,137.3,529.3,,,,,,XR Humerus Left,73060,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,76815,"Abdominal ultrasound of pregnant uterus limited to fetal position, heart beat, and amniotic fluid volume (1 or more fetuses) [HCPCS 76815]",357.3,267.98,267.98,289.17,166.13,289.17,,,,,,XR Humerus Right,73060,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,605.12,92.55,635.38,,,,,,XR IVP,74400,0320,,739.9,554.925,554.925
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,76881,Arm or leg ultrasound (complete) [HCPCS 76881],465.3,348.98,348.98,366.52,180.66,366.52,,,,,,XR Knee 1 or 2 Views Left,73560,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,114.33,23.61,157.86,,,,,,XR Knee 1 or 2 Views Right,73560,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,253.05,89.59,349.41,,,,,,XR Knee 3 Views Left,73562,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,8.49,8.49,161,,,,,,XR Knee 3 Views Right,73562,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.6,8.87,355.2,,,,,,XR Knee Complete 4+ Views Left,73564,0320,,290.1,217.575,217.575
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,47.95,43.35,182.52,,,,,,XR Knee Complete 4+ Views Right,73564,0320,,290.1,217.575,217.575
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,13.43,11.25,148.9,,,,,,XR Knee 1 View Standing AP Bilateral,73565,0320,,236,177,177
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,14.59,14.4,297.7,,,,,,XR Lower Extremity Infant (0-1yr) Left,73592,0320,,223.9,167.925,167.925
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.19,2.66,76.2,,,,,,XR Lower Extremity Infant (0-1yr) Right,73592,0320,,223.9,167.925,167.925
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,2.25,1.89,53,,,,,,XR Mandible Complete 4+ Views,70110,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,7,6.2,81.6,,,,,,XR Mandible Less Than 4 Views,70100,0320,,228.3,171.225,171.225
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,81511,"Lab analysis of four analytes (afp, ue3, hcg [any form], dia) from maternal serum to identify the risk of fetal birth defects [HCPCS 81511]",657.1,492.83,492.83,124.73,124.73,771.24,,,,,,XR Nasal Bones 3+ Views,70160,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,5.8,2.31,20.91,,,,,,XR Neck Soft Tissue,70360,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,6.5,5.44,96,,,,,,XR Orbits Complete,70200,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,6.54,5.81,65.1,,,,,,XR Pelvis 1 or 2 Views,72170,0320,,98.2,73.65,73.65
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,11.59,11.55,98.31,,,,,,XR Pelvis Complete 3+ Views,72190,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,5.19,4.35,81.23,,,,,,XR Ribs 2 Views Left,71100,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,0,32.34,465.3,,,,,,XR Ribs 2 Views Right,71100,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,13.68,11.45,112.4,,,,,,XR Ribs 3 Views Bilateral,71110,0320,,236,177,177
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,12.91,10.81,66.12,,,,,,XR Ribs w/ PA Chest Bilateral,71111,0320,,187.5,140.625,140.625
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,2.66,2.66,8.7,,,,,,XR Ribs w/ PA Chest Left,71101,0320,,262.4,196.8,196.8
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,9.74,8.16,104.31,,,,,,XR Ribs w/ PA Chest Right,71101,0320,,262.4,196.8,196.8
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,10.71,9.72,190.22,,,,,,XR Sacroiliac Joints 1 or 2 Views,72200,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,6.05,5.07,94.54,,,,,,XR Sacroiliac Joints 3+ Views,72202,0320,,231.6,173.7,173.7
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,6.91,5,105.9,,,,,,XR Sacrum/Coccyx 2+ Views,72220,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,6.73,5.63,72.8,,,,,,XR Scapula Left,73010,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,4.75,4.75,40.9,,,,,,XR Scapula Right,73010,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,18.45,18.45,315.4,,,,,,XR Sella Turcica,70240,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84402,Lab analysis to measure free testosterone (hormone) level in serum specimen [HCPCS 84402],148.9,111.68,111.68,25.55,25.55,148.9,,,,,,XR Shoulder 1 View Left,73020,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,25.9,25.9,240.4,,,,,,XR Shoulder 1 View Right,73020,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,9.04,7.58,134.6,,,,,,XR Shoulder Complete 2+ Views Left,73030,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,16.86,14.11,134.34,,,,,,XR Shoulder Complete 2+ Views Right,73030,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,10.14,9.87,141.2,,,,,,XR Sinuses Paranasal < 3 Views,73030,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,4.54,4.54,50.4,,,,,,XR Sinuses Paranasal Complete,70220,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,15.1,12.64,85.85,,,,,,XR Skull < 4 Views,70250,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.79,6,88.2,,,,,,XR Skull Complete,70260,0320,,377.1,282.825,282.825
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,6.49,5.43,37.5,,,,,,XR Small Bowel w/ Multiple Series,74250,0320,,465.3,348.975,348.975
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,10.2,8.55,182.7,,,,,,XR Spine Cervical 1 View,72020,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,3.94,3.6,69.6,,,,,,XR Spine Lumbar 1 View,72020,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,2.7,2.7,54.33,,,,,,XR Spine Cervical 2 or 3 Views,72040,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,6.03,6.03,69.6,,,,,,XR Spine Cervical 4 or 5 Views,72050,0320,,355,266.25,266.25
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,13.75,11.52,121.3,,,,,,XR Spine Cervical 6+ Views,72052,0320,,377.1,282.825,282.825
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,8.65,7.24,496.86,,,,,,XR Spine Lumbosacral 2 or 3 Views,72100,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,8.1,6.79,100.4,,,,,,XR Spine Lumbosacral Bending 2-3 Views,72120,0320,,377.1,282.825,282.825
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,6.65,5.57,65.1,,,,,,XR Spine Lumbosacral w/ Bending 6+ Views,72114,0320,,561.3,420.975,420.975
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,8.09,2.84,108.1,,,,,,XR Spine Lumbosacral 4+ Views,72110,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,8.11,6.8,52.43,,,,,,XR Spine Thoracic 2 Views,72070,0320,,246,184.5,184.5
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87339,Lab analysis by immunoassay (ELISA) to identify helicobacter pylori (GI tract bacteria) [HCPCS 87339],217.3,162.98,162.98,13,13,16,,,,,,XR Spine Thoracic 3 Views,72072,0320,,249.2,186.9,186.9
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,12.03,8.17,155.5,,,,,,XR Spine Thoracolumbar 2+ Views,72080,0320,,121.3,90.975,90.975
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,45.23,37.79,110.3,,,,,,XR Sternum 2+ Views,71120,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,74.6,14.12,74.6,,,,,,XR TMJ Open and Closed Bilateral,70330,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,35.2,29.48,155.5,,,,,,XR Tibia/Fibula Left,73590,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,35.2,29.48,155.5,,,,,,XR Tibia/Fibula Right,73590,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,35.2,4.29,35.67,,,,,,XR Toe(s) 2+ Views Left,73660,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.31,45.82,378.9,,,,,,XR Toe(s) 2+ Views Right,73660,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,35.2,29.48,105,,,,,,XR Upper Extremity Infant (0-1yr) Left,73092,0320,,223.9,167.925,167.925
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,40.24,40.24,406.9,,,,,,XR Upper Extremity Infant (0-1yr) Right,73092,0320,,223.9,167.925,167.925
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,26.58,4.29,27.04,,,,,,XR Wrist 2 Views Left,73100,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,104.13,6.15,4344.87,,,,,,XR Wrist 2 Views Right,73100,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,606.39,166.13,1092.27,,,,,,XR Wrist Complete 3+ Views Left,73110,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,94010,Total and timed exhaled air capacity measurement and graphic recording [HCPCS 94010],261.4,196.05,196.05,222.19,21.05,222.19,,,,,,XR Wrist Complete 3+ Views Right,73110,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,71.23,16.49,98.36,,,,,,Unattended Electrical Therapy Charge,97014,0420,,62.9,47.175,47.175
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,448.97,19.15,448.97,,,,,,PT Biofeedback Units,90901,0420,,354,265.5,265.5
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,Level 4,,0360,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,Level 1,,0360,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,0,68.61,524.17,,,,,,Level 2,,0360,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,63.41,4.51,1156.79,,,,,,Level 3,,0360,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,Level 5,,0360,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,0,12.56,48.28,,,,,,B-Type Natriuretic Peptide,,,,,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,0,10.24,44.01,,,,,,Glucose POCT,82962,0300,,9.2,6.9,6.9
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,41.31,13.42,41.31,,,,,,Spinal,,0370,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,95.63,40.84,136.8,,,,,,Monitored Anesthesia Care,,0370,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,71.23,23.51,98.36,,,,,,General,,0370,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,310.25,140.59,428.4,,,,,,Moderate Sedation,,0370,,0,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,28.14,10.32,28.14,,,,,,"96360 - ED Hydration, first hour",96360,0450,,446.6,334.95,334.95
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,208.08,39.1,434.06,,,,,,"96361- ED Hydration, each additional hour",96361,0450,,97.1,72.825,72.825
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,327.16,61.48,2109.82,,,,,,"96365- ED IV tx, first hour",96365,0450,,446.6,334.95,334.95
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,461.47,50,3116.59,,,,,,"96366- ED IV tx, each additional hour",96366,0450,,97.1,72.825,72.825
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,795.69,62.92,1098.7,,,,,,"96367- ED IV tx, sequential infusion",96367,0450,,81.6,61.2,61.2
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,20.66,5.83,3301.98,,,,,,"96368- ED IV tx, concurrent infusion",96368,0450,,81.6,61.2,61.2
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,G0480,Drug test def 1-7 classes [HCPCS G0480],188.6,141.45,141.45,92.98,92.98,92.98,,,,,,96372- ED Subq/IM Injection,96372,0450,,78.4,58.8,58.8
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,10.63,5.5,14.67,,,,,,96373- Intra-Arterial Injection,,,,,,
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,5.31,0.68,2868.2,,,,,,"96374- ED IV Injection, single/initial",96374,0450,,199.6,149.7,149.7
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,2.13,0.73,808.23,,,,,,"96375- ED IV Injection, add new drug",96375,0450,,39.7,29.775,29.775
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,10.63,5.5,14.67,,,,,,"96376- ED IV Injection, add same drug",96376,0450,,39.7,29.775,29.775
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,21.25,3.15,30.39,,,,,,ROOM/BED: ICU,,0200,,"1,550.2",1162.65,1162.65
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,10.63,0.95,3583.7,,,,,,ROOM/BED: Observation,G0378,0762,,24.3,18.225,18.225
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,1.06,0.55,29.34,,,,,,Electrocardiogram 12 Lead,93005,0730,,122.5,91.875,91.875
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J2920,Methylprednisolone injection [HCPCS J2920],25,18.75,18.75,21.25,5.3,21.25,,,,,,CT Abdomen and Pelvis w/ + w/o Contrast,74178,0352,,"3,140",2355,2355
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,24.72,5.49,347.63,,,,,,CT Abdomen and Pelvis w/ Contrast,74177,0352,,"2,510.5",1882.875,1882.875
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,5.42,1.29,348.28,,,,,,CT Abdomen and Pelvis w/o Contrast,74176,0352,,"2,489.5",1867.125,1867.125
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,1.76,23.48,,,,,,CT Angio Chest TAVI,71275,0352,,"1,412.4",1059.3,1059.3
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,29.75,0.02,4433.9,,,,,,CT Stone Protocol,74176,0352,,"2,489.5",1867.125,1867.125
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J7510,Prednisolone oral per 5 mg [HCPCS J7510],10.36,7.77,7.77,8.81,2.49,8.81,,,,,,US Extremity Nonvascular Complete Left,76881,0402,,465.3,348.975,348.975
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,4.25,2.4,4.25,,,,,,US Extremity Nonvascular Complete Right,76881,0402,,431.2,323.4,323.4
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J7614,Levalbuterol non-comp unit [HCPCS J7614],5.58,4.19,4.19,5.7,3.39,5.7,,,,,,US Extremity Nonvascular Limited Left,76882,0402,,54.1,40.575,40.575
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Hospital,Institutional,Outpatient,J7620,Albuterol ipratrop non-comp [HCPCS J7620],5.47,4.1,4.1,4.65,2.41,4.65,,,,,,US Extremity Nonvascular Limited Right,76882,0402,,54.1,40.575,40.575
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],49.7,37.28,37.28,69.32,69.32,94.91,,,,,,US Pelvis Comp w/Transvag if indicated,76856,0402,,561.3,420.975,420.975
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",314,235.5,235.5,74.25,55.67,329.7,,,,,,XR Placement CVAD w/ Fluoro,77001,0320,,231.6,173.7,173.7
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,6.58,1.93,464.4,,,,,,XR Reposition CVAD w/ Fluoro,36597,0320,,225,168.75,168.75
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,14,3.36,245.34,,,,,,MRI Cardiac Morph Fnct w/ + w/o Cnt,75561,0610,,"1,974.7",1481.025,1481.025
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,168.37,168.37,416.16,,,,,,MRI Cardiac Morph Fnct w/o Cnt,75557,0610,,"1,046.4",784.8,784.8
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,801.74,583.91,1462.85,,,,,,CN 100% impaired,G9165,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,44.01,13.55,72.8,,,,,,CM At least 80% but less than 100% impaired,G9165,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,74.6,52.38,170.1,,,,,,CL At least 60% but less than 80% impaired,G9165,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,69.32,52.53,206.9,,,,,,CK At least 40% but less than 60% impaired,G9165,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,194.57,59.92,194.57,,,,,,CJ At least 20% but less than 40% impaired,G9165,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,142.6,95.05,222.03,,,,,,CI At least 1% but less than 20% impaired,G9165,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,41.43,31.68,51.15,,,,,,CH 0% impaired,G9165,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,74.84,45.48,91.29,,,,,,CN 100% impaired,G9167,0430,,0.01,0.0075,0.0075
GREATWESTHEALTHCARE-CIGNA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,74.25,59.99,274.04,,,,,,CM At least 80% but less than 100% impaired,G9167,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],3533.3,2649.98,2649.98,15.78,8.8,16.21,,,,,,CL At least 60% but less than 80% impaired,G9167,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,184.78,7.21,246,,,,,,CK At least 40% but less than 60% impaired,G9167,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],283.5,212.63,212.63,223.68,9.98,223.68,,,,,,CJ At least 20% but less than 40% impaired,G9167,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],72.5,54.38,54.38,57.2,3.22,57.2,,,,,,CI At least 1% but less than 20% impaired,G9167,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,61.31,5.3,61.31,,,,,,CH 0% impaired,G9167,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],129.2,96.9,96.9,101.94,17.07,101.94,,,,,,CN 100% impaired,G9166,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",84,63,63,66.28,5.31,66.28,,,,,,CM At least 80% but less than 100% impaired,G9166,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],116.6,87.45,87.45,92,7.4,100.98,,,,,,CL At least 60% but less than 80% impaired,G9166,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],425.3,318.98,318.98,335.56,335.56,344.79,,,,,,CK At least 40% but less than 60% impaired,G9166,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],447.7,335.78,335.78,428.35,428.35,1744.38,,,,,,CJ At least 20% but less than 40% impaired,G9166,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,113,35.11,337.46,,,,,,CI At least 1% but less than 20% impaired,G9166,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,113,70.45,319.43,,,,,,CH 0% impaired,G9166,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,113,113,283.23,,,,,,CN 100% impaired,G8981,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Institutional,Outpatient,G0438,"Ppps, initial visit [HCPCS G0438]",68.4,51.3,51.3,113,113,283.23,,,,,,CM At least 80% but less than 100% impaired,G8981,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,61.31,5.3,61.31,,,,,,CL At least 60% but less than 80% impaired,G8981,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,15.07,1.28,46.3,,,,,,CK At least 40% but less than 60% impaired,G8981,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,63.97,36.98,63.97,,,,,,CJ At least 20% but less than 40% impaired,G8981,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,60.95,45.56,141.93,,,,,,CI At least 1% but less than 20% impaired,G8981,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,93.83,91.42,145.6,,,,,,CH 0% impaired,G8981,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],281.2,210.9,210.9,205.03,185.38,251.35,,,,,,CN 100% impaired,G8983,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.05,13.55,72.8,,,,,,CM At least 80% but less than 100% impaired,G8983,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,105.9,62.38,245.75,,,,,,CL At least 60% but less than 80% impaired,G8983,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,108.68,70,166.6,,,,,,CK At least 40% but less than 60% impaired,G8983,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,151.75,147.2,226.48,,,,,,CJ At least 20% but less than 40% impaired,G8983,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Inpatient,310,Abnormal or Irregular Heartbeat without complications,9139.9,6854.93,6854.93,4356,8.28,4356,,,,,,CI At least 1% but less than 20% impaired,G8983,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Inpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,11.18,5.83,3301.98,,,,,,CH 0% impaired,G8983,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,CN 100% impaired,G8982,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,115.18,20.71,250.4,,,,,,CM At least 80% but less than 100% impaired,G8982,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,103.5,4.41,166.13,,,,,,CL At least 60% but less than 80% impaired,G8982,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,177.53,29.4,177.53,,,,,,CK At least 40% but less than 60% impaired,G8982,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,177.53,94.25,214.2,,,,,,CJ At least 20% but less than 40% impaired,G8982,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,177.53,69.84,225,,,,,,CI At least 1% but less than 20% impaired,G8982,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,74170,"Abdominal CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74170]",1572.2,1179.15,1179.15,723.21,658.81,723.21,,,,,,CH 0% impaired,G8982,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1964.22,180.22,3324.06,,,,,,CN 100% impaired,G8984,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,193.75,166.13,421.2,,,,,,CM At least 80% but less than 100% impaired,G8984,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,515.93,166.13,529.3,,,,,,CL At least 60% but less than 80% impaired,G8984,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,300.79,107.93,965.26,,,,,,CK At least 40% but less than 60% impaired,G8984,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,106.12,23.61,157.86,,,,,,CJ At least 20% but less than 40% impaired,G8984,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],485.7,364.28,364.28,383.22,84.74,462.5,,,,,,CI At least 1% but less than 20% impaired,G8984,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,0,108.36,412.85,,,,,,CH 0% impaired,G8984,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,234.89,89.59,349.41,,,,,,CN 100% impaired,G8986,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,74.06,8.49,161,,,,,,CM At least 80% but less than 100% impaired,G8986,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,113.16,8.87,355.2,,,,,,CL At least 60% but less than 80% impaired,G8986,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,117.48,11.25,148.9,,,,,,CK At least 40% but less than 60% impaired,G8986,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,234.89,14.4,297.7,,,,,,CJ At least 20% but less than 40% impaired,G8986,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,9.42,73.71,,,,,,CI At least 1% but less than 20% impaired,G8986,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,60.12,2.66,76.2,,,,,,CH 0% impaired,G8986,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,24.38,1.89,53,,,,,,CN 100% impaired,G8985,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,64.38,6.2,81.6,,,,,,CM At least 80% but less than 100% impaired,G8985,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,12.19,2.31,20.91,,,,,,CL At least 60% but less than 80% impaired,G8985,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,75.74,5.44,96,,,,,,CK At least 40% but less than 60% impaired,G8985,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,38.5,16.18,45.86,,,,,,CJ At least 20% but less than 40% impaired,G8985,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,228.89,30.08,290.1,,,,,,CI At least 1% but less than 20% impaired,G8985,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,51.36,5.81,65.1,,,,,,CH 0% impaired,G8985,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,78.35,11.55,98.31,,,,,,CN 100% impaired,G9168,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,22.86,5.2,40.9,,,,,,CM At least 80% but less than 100% impaired,G9168,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,44.67,4.35,81.23,,,,,,CL At least 60% but less than 80% impaired,G9168,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,98.39,12.67,98.39,,,,,,CK At least 40% but less than 60% impaired,G9168,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,214.04,32.34,465.3,,,,,,CJ At least 20% but less than 40% impaired,G9168,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,192.28,14.94,192.28,,,,,,CI At least 1% but less than 20% impaired,G9168,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,0,2.66,8.7,,,,,,CH 0% impaired,G9168,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,53.31,8.16,104.31,,,,,,CN 100% impaired,G9170,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,83.56,5,105.9,,,,,,CM At least 80% but less than 100% impaired,G9170,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,33.49,5.63,72.8,,,,,,CL At least 60% but less than 80% impaired,G9170,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,129.86,32.98,268.8,,,,,,CK At least 40% but less than 60% impaired,G9170,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84425,Lab analysis to measure the vitamin B-1 (thiamine) level in blood specimen [HCPCS 84425],311,233.25,233.25,245.38,130.28,245.38,,,,,,CJ At least 20% but less than 40% impaired,G9170,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,59.85,7.58,134.6,,,,,,CI At least 1% but less than 20% impaired,G9170,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,62.42,14.11,134.34,,,,,,CH 0% impaired,G9170,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,71.53,14.41,153.94,,,,,,CN 100% impaired,G9169,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",233.8,175.35,175.35,184.47,17.22,200.91,,,,,,CM At least 80% but less than 100% impaired,G9169,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,64.95,9.87,141.2,,,,,,CL At least 60% but less than 80% impaired,G9169,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,24.38,4.02,32.1,,,,,,CK At least 40% but less than 60% impaired,G9169,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,24.38,4.54,50.4,,,,,,CJ At least 20% but less than 40% impaired,G9169,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,89.79,17.05,191.3,,,,,,CI At least 1% but less than 20% impaired,G9169,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,40.57,6,88.2,,,,,,CH 0% impaired,G9169,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,32.02,3.6,69.6,,,,,,CN 100% impaired,G8978,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,122.69,12.29,258.33,,,,,,CM At least 80% but less than 100% impaired,G8978,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,86141,Lab analysis to measure the amount of C-reactive protein in serum by high sensitivity assay to identify infection or inflammation [HCPCS 86141],155.5,116.63,116.63,0,22.11,65.16,,,,,,CL At least 60% but less than 80% impaired,G8978,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,48.76,4.34,61.8,,,,,,CK At least 40% but less than 60% impaired,G8978,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,95.71,11.52,121.3,,,,,,CJ At least 20% but less than 40% impaired,G8978,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,175.71,11.99,222.7,,,,,,CI At least 1% but less than 20% impaired,G8978,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,78.35,7.24,496.86,,,,,,CH 0% impaired,G8978,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,43.98,6.79,100.4,,,,,,CN 100% impaired,G8980,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,85.29,2.84,108.1,,,,,,CM At least 80% but less than 100% impaired,G8980,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,19.57,6.8,52.43,,,,,,CL At least 60% but less than 80% impaired,G8980,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,122.69,8.17,155.5,,,,,,CK At least 40% but less than 60% impaired,G8980,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,0,37.79,110.3,,,,,,CJ At least 20% but less than 40% impaired,G8980,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,58.86,14.12,74.6,,,,,,CI At least 1% but less than 20% impaired,G8980,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,122.69,29.48,155.5,,,,,,CH 0% impaired,G8980,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,122.69,29.48,155.5,,,,,,CN 100% impaired,G8979,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,13.97,4.29,35.67,,,,,,CM At least 80% but less than 100% impaired,G8979,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,130.5,45.82,378.9,,,,,,CL At least 60% but less than 80% impaired,G8979,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,82.85,29.48,105,,,,,,CK At least 40% but less than 60% impaired,G8979,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,0,4.29,27.04,,,,,,CJ At least 20% but less than 40% impaired,G8979,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,56.35,6.15,4344.87,,,,,,CI At least 1% but less than 20% impaired,G8979,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,215.6,39.27,311.42,,,,,,CH 0% impaired,G8979,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,66.12,19.15,448.97,,,,,,CN 100% impaired,G8990,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,352.37,28.6,1161.38,,,,,,CM At least 80% but less than 100% impaired,G8990,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,35.51,16.26,2475.42,,,,,,CL At least 60% but less than 80% impaired,G8990,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,61.86,4.51,1156.79,,,,,,CK At least 40% but less than 60% impaired,G8990,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,91.82,29.4,2785.69,,,,,,CJ At least 20% but less than 40% impaired,G8990,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,31.32,12.56,48.28,,,,,,CI At least 1% but less than 20% impaired,G8990,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,17.25,10.24,44.01,,,,,,CH 0% impaired,G8990,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,0,13.42,41.31,,,,,,CN 100% impaired,G8992,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,68.36,40.84,136.8,,,,,,CM At least 80% but less than 100% impaired,G8992,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,66.12,23.51,98.36,,,,,,CL At least 60% but less than 80% impaired,G8992,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,287.99,140.59,428.4,,,,,,CK At least 40% but less than 60% impaired,G8992,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,183.92,39.1,434.06,,,,,,CJ At least 20% but less than 40% impaired,G8992,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,303.69,61.48,2109.82,,,,,,CI At least 1% but less than 20% impaired,G8992,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,262.25,50,3116.59,,,,,,CH 0% impaired,G8992,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,430.61,62.92,1098.7,,,,,,CN 100% impaired,G8991,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,117.17,2.42,250.2,,,,,,CM At least 80% but less than 100% impaired,G8991,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,11.18,5.83,3301.98,,,,,,CL At least 60% but less than 80% impaired,G8991,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,J0360,Hydralazine hcl injection [HCPCS J0360],36,27,27,16.56,6.88,317.84,,,,,,CK At least 40% but less than 60% impaired,G8991,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,43.79,13.53,65.14,,,,,,CJ At least 20% but less than 40% impaired,G8991,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,19.73,7.08,29.34,,,,,,CI At least 1% but less than 20% impaired,G8991,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,9.87,0.95,3583.7,,,,,,CH 0% impaired,G8991,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,16.1,0.02,4433.9,,,,,,CN 100% impaired,G8987,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,0,2.4,4.25,,,,,,CM At least 80% but less than 100% impaired,G8987,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Hospital,Institutional,Outpatient,J7633,Budesonide non-comp con [HCPCS J7633],27.7,20.78,20.78,11.84,9.12,482.83,,,,,,CL At least 60% but less than 80% impaired,G8987,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,94.91,52.53,206.9,,,,,,CK At least 40% but less than 60% impaired,G8987,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.53,22.37,41.75,,,,,,CJ At least 20% but less than 40% impaired,G8987,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,69.53,45.48,91.29,,,,,,CI At least 1% but less than 20% impaired,G8987,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,126.93,114.76,176.55,,,,,,CH 0% impaired,G8987,0430,,0.01,0.0075,0.0075
AETNA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,102.94,33.41,326.4,,,,,,CN 100% impaired,G8989,0430,,0.01,0.0075,0.0075
HALLCON INC. - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,95.76,62.38,245.75,,,,,,CM At least 80% but less than 100% impaired,G8989,0430,,0.01,0.0075,0.0075
HALLCON INC. - Commercial-PPO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,226.48,147.2,226.48,,,,,,CL At least 60% but less than 80% impaired,G8989,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],339.4,254.55,254.55,0,72.62,77.09,,,,,,CK At least 40% but less than 60% impaired,G8989,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,0,5.19,5.3,,,,,,CJ At least 20% but less than 40% impaired,G8989,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,63.14,45.56,141.93,,,,,,CI At least 1% but less than 20% impaired,G8989,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,0,13.55,72.8,,,,,,CH 0% impaired,G8989,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,100.8,62.38,245.75,,,,,,CN 100% impaired,G8988,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,0,1.1,17.76,,,,,,CM At least 80% but less than 100% impaired,G8988,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-Indemnity,Hospital,Institutional,Outpatient,99199,"Unlisted procedure, service, or report [HCPCS 99199]",233.1,174.83,174.83,174.79,167.61,8028.2,,,,,,CL At least 60% but less than 80% impaired,G8988,0430,,0.01,0.0075,0.0075
HAWAII MAINLAND ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,79.25,62.38,245.75,,,,,,CK At least 40% but less than 60% impaired,G8988,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,0,5.03,33.1,,,,,,CJ At least 20% but less than 40% impaired,G8988,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,CI At least 1% but less than 20% impaired,G8988,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,0,18.04,43.1,,,,,,CH 0% impaired,G8988,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,0,18.04,43.1,,,,,,CN 100% impaired,G8993,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,0,5.2,40.9,,,,,,CM At least 80% but less than 100% impaired,G8993,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,0,3.99,48.28,,,,,,CL At least 60% but less than 80% impaired,G8993,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,0,5.07,94.54,,,,,,CK At least 40% but less than 60% impaired,G8993,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,0,13.86,33.1,,,,,,CJ At least 20% but less than 40% impaired,G8993,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,0,4.75,40.9,,,,,,CI At least 1% but less than 20% impaired,G8993,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,0,7.89,28.7,,,,,,CH 0% impaired,G8993,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,CN 100% impaired,G8995,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,0,18.48,44.1,,,,,,CM At least 80% but less than 100% impaired,G8995,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,0,4.35,39.58,,,,,,CL At least 60% but less than 80% impaired,G8995,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,0,4.02,32.1,,,,,,CK At least 40% but less than 60% impaired,G8995,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,284.74,105.86,1389.2,,,,,,CJ At least 20% but less than 40% impaired,G8995,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,CI At least 1% but less than 20% impaired,G8995,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,300.05,70.45,319.43,,,,,,CH 0% impaired,G8995,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,0,4,9.09,,,,,,CN 100% impaired,G8994,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,CM At least 80% but less than 100% impaired,G8994,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,142.73,20.71,250.4,,,,,,CL At least 60% but less than 80% impaired,G8994,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,148.6,109.96,166.13,,,,,,CK At least 40% but less than 60% impaired,G8994,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,140.22,8.87,355.2,,,,,,CJ At least 20% but less than 40% impaired,G8994,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,37.11,5.81,65.1,,,,,,CI At least 1% but less than 20% impaired,G8994,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,56.6,11.55,98.31,,,,,,CH 0% impaired,G8994,0430,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,80.48,9.87,141.2,,,,,,CN 100% impaired,G8983,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,50.27,6,88.2,,,,,,CM At least 80% but less than 100% impaired,G8983,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,109.38,8.55,182.7,,,,,,CL At least 60% but less than 80% impaired,G8983,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,39.67,3.6,69.6,,,,,,CK At least 40% but less than 60% impaired,G8983,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,62.87,37.79,110.3,,,,,,CJ At least 20% but less than 40% impaired,G8983,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.83,6.15,4344.87,,,,,,CI At least 1% but less than 20% impaired,G8983,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,47.77,16.49,98.36,,,,,,CH 0% impaired,G8983,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,94660,CPAP (continuous positive airway pressure) mask or breathing tube initiation and management for night time respiratory muscle rest [HCPCS 94660],548,411,411,312.36,229.64,312.36,,,,,,CN 100% impaired,G8982,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,113.77,29.4,2785.69,,,,,,CM At least 80% but less than 100% impaired,G8982,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.63,12.56,48.28,,,,,,CL At least 60% but less than 80% impaired,G8982,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,533.58,62.92,1098.7,,,,,,CK At least 40% but less than 60% impaired,G8982,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,7.13,5.5,1162.88,,,,,,CJ At least 20% but less than 40% impaired,G8982,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,14.25,7.08,29.34,,,,,,CI At least 1% but less than 20% impaired,G8982,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,16.58,5.49,347.63,,,,,,CH 0% impaired,G8982,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,344.7,214.38,2255.8,,,,,,CN 100% impaired,G8984,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,68.96,45.48,91.29,,,,,,CM At least 80% but less than 100% impaired,G8984,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.58,59.99,274.04,,,,,,CL At least 60% but less than 80% impaired,G8984,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,CK At least 40% but less than 60% impaired,G8984,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,CJ At least 20% but less than 40% impaired,G8984,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,1534.78,393.52,2894.06,,,,,,CI At least 1% but less than 20% impaired,G8984,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,CH 0% impaired,G8984,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,104.9,20.71,250.4,,,,,,CN 100% impaired,G8986,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,154.64,28.74,271.3,,,,,,CM At least 80% but less than 100% impaired,G8986,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1419.02,180.22,3324.06,,,,,,CL At least 60% but less than 80% impaired,G8986,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1362.81,561.23,2500,,,,,,CK At least 40% but less than 60% impaired,G8986,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,140.22,8.87,355.2,,,,,,CJ At least 20% but less than 40% impaired,G8986,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,0,11.25,148.9,,,,,,CI At least 1% but less than 20% impaired,G8986,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,31.9,2.66,76.2,,,,,,CH 0% impaired,G8986,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,26.96,5.2,40.9,,,,,,CN 100% impaired,G8985,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,0,32.34,465.3,,,,,,CM At least 80% but less than 100% impaired,G8985,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,0,11.45,112.4,,,,,,CL At least 60% but less than 80% impaired,G8985,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,88.64,5.07,94.54,,,,,,CK At least 40% but less than 60% impaired,G8985,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,0,14.11,134.34,,,,,,CJ At least 20% but less than 40% impaired,G8985,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,28.73,4.02,32.1,,,,,,CI At least 1% but less than 20% impaired,G8985,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,50.27,6,88.2,,,,,,CH 0% impaired,G8985,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,109.38,8.55,182.7,,,,,,CN 100% impaired,G8980,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,0,3.6,69.6,,,,,,CM At least 80% but less than 100% impaired,G8980,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,0,6.03,69.6,,,,,,CL At least 60% but less than 80% impaired,G8980,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.06,6.79,100.4,,,,,,CK At least 40% but less than 60% impaired,G8980,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,0,2.84,108.1,,,,,,CJ At least 20% but less than 40% impaired,G8980,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.07,7.27,172,,,,,,CI At least 1% but less than 20% impaired,G8980,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,51.3,6.15,4344.87,,,,,,CH 0% impaired,G8980,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,CN 100% impaired,G8987,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,131.34,95.05,222.03,,,,,,CM At least 80% but less than 100% impaired,G8987,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,69.53,45.48,91.29,,,,,,CL At least 60% but less than 80% impaired,G8987,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.82,59.99,274.04,,,,,,CK At least 40% but less than 60% impaired,G8987,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],415.7,311.78,311.78,86.79,86.79,92.46,,,,,,CJ At least 20% but less than 40% impaired,G8987,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,42.53,41.76,46.23,,,,,,CI At least 1% but less than 20% impaired,G8987,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,88.11,87.72,88.11,,,,,,CH 0% impaired,G8987,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF NM-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",333,249.75,249.75,70.49,69.22,77.17,,,,,,CN 100% impaired,G8989,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,0,5.03,33.1,,,,,,CM At least 80% but less than 100% impaired,G8989,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,CL At least 60% but less than 80% impaired,G8989,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,0,18.04,43.1,,,,,,CK At least 40% but less than 60% impaired,G8989,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,0,18.04,43.1,,,,,,CJ At least 20% but less than 40% impaired,G8989,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,0,4.42,42.84,,,,,,CI At least 1% but less than 20% impaired,G8989,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,0,5.2,40.9,,,,,,CH 0% impaired,G8989,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,0,3.99,48.28,,,,,,CN 100% impaired,G8988,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,0,5.07,94.54,,,,,,CM At least 80% but less than 100% impaired,G8988,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,0,13.86,33.1,,,,,,CL At least 60% but less than 80% impaired,G8988,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,0,4.75,40.9,,,,,,CK At least 40% but less than 60% impaired,G8988,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,0,7.89,28.7,,,,,,CJ At least 20% but less than 40% impaired,G8988,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,CI At least 1% but less than 20% impaired,G8988,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,0,18.48,44.1,,,,,,CH 0% impaired,G8988,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,0,4.35,39.58,,,,,,CN 100% impaired,G8978,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,0,5.83,44.1,,,,,,CM At least 80% but less than 100% impaired,G8978,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,0,4.02,32.1,,,,,,CL At least 60% but less than 80% impaired,G8978,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,266.16,105.86,1389.2,,,,,,CK At least 40% but less than 60% impaired,G8978,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,310.8,131.45,310.8,,,,,,CJ At least 20% but less than 40% impaired,G8978,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,320.84,266.1,323.65,,,,,,CI At least 1% but less than 20% impaired,G8978,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,CH 0% impaired,G8978,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,CN 100% impaired,G8979,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,309.38,107.28,315.01,,,,,,CM At least 80% but less than 100% impaired,G8979,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,J0606,"Inj, etelcalcetide, 0.1 mg [HCPCS J0606]",6.84,5.13,5.13,0,4.57,4.57,,,,,,CL At least 60% but less than 80% impaired,G8979,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,0,6.13,13.93,,,,,,CK At least 40% but less than 60% impaired,G8979,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,0,1.1,3.07,,,,,,CJ At least 20% but less than 40% impaired,G8979,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Clinic,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0,0.63,1.44,,,,,,CI At least 1% but less than 20% impaired,G8979,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,55,55,125,,,,,,CH 0% impaired,G8979,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,CN 100% impaired,G8999,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,896.15,137.3,1347.57,,,,,,CM At least 80% but less than 100% impaired,G8999,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,142.73,20.71,250.4,,,,,,CL At least 60% but less than 80% impaired,G8999,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,154.64,28.74,271.3,,,,,,CK At least 40% but less than 60% impaired,G8999,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,126.58,94.25,177.23,,,,,,CJ At least 20% but less than 40% impaired,G8999,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,149.57,109.96,166.13,,,,,,CI At least 1% but less than 20% impaired,G8999,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,126.58,69.84,223.7,,,,,,CH 0% impaired,G8999,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,742.82,166.13,1107.72,,,,,,CN 100% impaired,G8992,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,73000,"Collar bone x-ray, complete study [HCPCS 73000]",225,168.75,168.75,126.58,123.34,126.58,,,,,,CM At least 80% but less than 100% impaired,G8992,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,128.25,94.25,222.4,,,,,,CL At least 60% but less than 80% impaired,G8992,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],225,168.75,168.75,94.25,27.4,191.25,,,,,,CK At least 40% but less than 60% impaired,G8992,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,94.25,94.25,191.25,,,,,,CJ At least 20% but less than 40% impaired,G8992,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,122.09,57.76,225,,,,,,CI At least 1% but less than 20% impaired,G8992,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,128.25,94.25,214.2,,,,,,CH 0% impaired,G8992,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],1046.4,784.8,784.8,568.01,350.85,636.21,,,,,,CN 100% impaired,G8991,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,122.09,90,225,,,,,,CM At least 80% but less than 100% impaired,G8991,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1412.41,561.23,2500,,,,,,CL At least 60% but less than 80% impaired,G8991,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,367.88,166.13,529.3,,,,,,CK At least 40% but less than 60% impaired,G8991,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,76.67,23.61,157.86,,,,,,CJ At least 20% but less than 40% impaired,G8991,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,91.09,89.59,349.41,,,,,,CI At least 1% but less than 20% impaired,G8991,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,91.77,8.49,161,,,,,,CH 0% impaired,G8991,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,0,41.68,551.29,,,,,,CN 100% impaired,G8993,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,137.42,8.87,355.2,,,,,,CM At least 80% but less than 100% impaired,G8993,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,84.87,11.25,148.9,,,,,,CL At least 60% but less than 80% impaired,G8993,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43.43,2.66,76.2,,,,,,CK At least 40% but less than 60% impaired,G8993,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,29.61,1.89,53,,,,,,CJ At least 20% but less than 40% impaired,G8993,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,37.11,5.81,65.1,,,,,,CI At least 1% but less than 20% impaired,G8993,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,71.08,12.67,98.39,,,,,,CH 0% impaired,G8993,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,138.91,14.94,192.28,,,,,,CN 100% impaired,G8995,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.19,2.66,8.7,,,,,,CM At least 80% but less than 100% impaired,G8995,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,66.06,8.16,104.31,,,,,,CL At least 60% but less than 80% impaired,G8995,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,57.46,5,105.9,,,,,,CK At least 40% but less than 60% impaired,G8995,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,118.27,32.98,268.8,,,,,,CJ At least 20% but less than 40% impaired,G8995,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,137.03,25.9,240.4,,,,,,CI At least 1% but less than 20% impaired,G8995,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,74.16,7.58,134.6,,,,,,CH 0% impaired,G8995,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,75.8,14.11,134.34,,,,,,CN 100% impaired,G8994,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,79.68,9.87,141.2,,,,,,CM At least 80% but less than 100% impaired,G8994,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,30.21,4.54,50.4,,,,,,CL At least 60% but less than 80% impaired,G8994,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,CK At least 40% but less than 60% impaired,G8994,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,109.38,8.55,182.7,,,,,,CJ At least 20% but less than 40% impaired,G8994,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,80.48,9.2,112.32,,,,,,CI At least 1% but less than 20% impaired,G8994,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,57.23,6.79,100.4,,,,,,CH 0% impaired,G8994,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,61.62,2.84,108.1,,,,,,CN 100% impaired,G8996,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,14.14,6.8,52.43,,,,,,CM At least 80% but less than 100% impaired,G8996,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,98.04,7.27,172,,,,,,CL At least 60% but less than 80% impaired,G8996,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,94.28,45.82,378.9,,,,,,CK At least 40% but less than 60% impaired,G8996,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.83,6.15,4344.87,,,,,,CJ At least 20% but less than 40% impaired,G8996,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,CI At least 1% but less than 20% impaired,G8996,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,52.67,16.26,2475.42,,,,,,CH 0% impaired,G8996,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,251.26,68.61,524.17,,,,,,CN 100% impaired,G8998,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,93.33,4.51,1156.79,,,,,,CM At least 80% but less than 100% impaired,G8998,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,113.77,29.4,2785.69,,,,,,CL At least 60% but less than 80% impaired,G8998,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.34,12.56,48.28,,,,,,CK At least 40% but less than 60% impaired,G8998,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,21.55,10.24,44.01,,,,,,CJ At least 20% but less than 40% impaired,G8998,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,27.7,13.42,41.31,,,,,,CI At least 1% but less than 20% impaired,G8998,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,64.13,40.84,136.8,,,,,,CH 0% impaired,G8998,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,68.92,40.84,143.78,,,,,,CN 100% impaired,G8997,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,47.46,23.51,98.36,,,,,,CM At least 80% but less than 100% impaired,G8997,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,208.05,140.59,428.4,,,,,,CL At least 60% but less than 80% impaired,G8997,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,102.56,39.1,434.06,,,,,,CK At least 40% but less than 60% impaired,G8997,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,219.39,61.48,2109.82,,,,,,CJ At least 20% but less than 40% impaired,G8997,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,320.74,50,3116.59,,,,,,CI At least 1% but less than 20% impaired,G8997,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,530.12,62.92,1098.7,,,,,,CH 0% impaired,G8997,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,G0283,Elec stim other than wound [HCPCS G0283],62.9,47.18,47.18,35.85,26.36,35.85,,,,,,CN 100% impaired,G9165,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,13.76,5.83,3301.98,,,,,,CM At least 80% but less than 100% impaired,G9165,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,J0692,Cefepime hcl for injection [HCPCS J0692],12.5,9.38,9.38,7.03,7.03,7.03,,,,,,CL At least 60% but less than 80% impaired,G9165,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,2.2,0.73,808.23,,,,,,CK At least 40% but less than 60% impaired,G9165,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,14.25,7.08,29.34,,,,,,CJ At least 20% but less than 40% impaired,G9165,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,14.06,7.8,30.4,,,,,,CI At least 1% but less than 20% impaired,G9165,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.13,0.95,3583.7,,,,,,CH 0% impaired,G9165,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,350.31,214.38,2255.8,,,,,,CN 100% impaired,G9167,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Dialysis Clinic,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,288.11,242.91,1540,,,,,,CM At least 80% but less than 100% impaired,G9167,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,68.7,52.38,170.1,,,,,,CL At least 60% but less than 80% impaired,G9167,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,93.46,52.53,206.9,,,,,,CK At least 40% but less than 60% impaired,G9167,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,191.66,120.14,248.05,,,,,,CJ At least 20% but less than 40% impaired,G9167,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,68.96,45.48,91.29,,,,,,CI At least 1% but less than 20% impaired,G9167,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,101.89,33.41,326.4,,,,,,CH 0% impaired,G9167,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99306,Initial nursing facility visit by admitting physician for problem of high severity (typically 45 minutes per day) [HCPCS 99306],759.7,569.78,569.78,159.51,159.51,159.51,,,,,,CN 100% impaired,G9166,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,66.42,66.42,66.64,,,,,,CM At least 80% but less than 100% impaired,G9166,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,87.72,87.72,88.11,,,,,,CL At least 60% but less than 80% impaired,G9166,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TEXAS-STD A & B - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99316,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, more than 30 minutes [HCPCS 99316]",481.9,361.43,361.43,100.36,100.36,101.6,,,,,,CK At least 40% but less than 60% impaired,G9166,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,323.65,266.1,323.65,,,,,,CJ At least 20% but less than 40% impaired,G9166,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,290.62,35.11,337.46,,,,,,CI At least 1% but less than 20% impaired,G9166,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,CH 0% impaired,G9166,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,309.38,107.28,315.01,,,,,,CN 100% impaired,G9168,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,344.55,236.82,344.55,,,,,,CM At least 80% but less than 100% impaired,G9168,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,364.61,231.95,364.61,,,,,,CL At least 60% but less than 80% impaired,G9168,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99310,Subsequent nursing facility visit for patient that is unstable or may have develped a major new problem requiring immediate physician attention (typically 35 minutes per day) [HCPCS 99310],617.4,463.05,463.05,344.18,260.49,344.18,,,,,,CK At least 40% but less than 60% impaired,G9168,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,12013,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.6 to 5.0 cm) [HCPCS 12013]",469.98,352.49,352.49,55,55,111.73,,,,,,CJ At least 20% but less than 40% impaired,G9168,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.73,2.44,580.94,,,,,,CI At least 1% but less than 20% impaired,G9168,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,70360,Neck x-ray to examine soft tissue for any obstructions and/or foreign bodies within the throat or neck [HCPCS 70360],225,168.75,168.75,127.42,94.25,182.07,,,,,,CH 0% impaired,G9168,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,658.81,137.3,1347.57,,,,,,CN 100% impaired,G9170,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,743.66,73.48,1221.85,,,,,,CM At least 80% but less than 100% impaired,G9170,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,104.9,20.71,250.4,,,,,,CL At least 60% but less than 80% impaired,G9170,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,113.65,28.74,271.3,,,,,,CK At least 40% but less than 60% impaired,G9170,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,546.08,166.13,1107.72,,,,,,CJ At least 20% but less than 40% impaired,G9170,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],98.2,73.65,73.65,41.14,41.14,166.13,,,,,,CI At least 1% but less than 20% impaired,G9170,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,94.25,18.85,148.78,,,,,,CH 0% impaired,G9170,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,127.42,56.37,178.99,,,,,,CN 100% impaired,G9169,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,370.3,107.93,965.26,,,,,,CM At least 80% but less than 100% impaired,G9169,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,67.45,8.49,161,,,,,,CL At least 60% but less than 80% impaired,G9169,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,140.22,8.87,355.2,,,,,,CK At least 40% but less than 60% impaired,G9169,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,31.9,2.66,76.2,,,,,,CJ At least 20% but less than 40% impaired,G9169,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,37.11,5.81,65.1,,,,,,CI At least 1% but less than 20% impaired,G9169,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,0,2.66,8.7,,,,,,CH 0% impaired,G9169,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,160.91,32.98,268.8,,,,,,CN 100% impaired,G9158,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,73.42,7.58,134.6,,,,,,CM At least 80% but less than 100% impaired,G9158,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,76.58,14.11,134.34,,,,,,CL At least 60% but less than 80% impaired,G9158,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,80.48,9.87,141.2,,,,,,CK At least 40% but less than 60% impaired,G9158,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,CJ At least 20% but less than 40% impaired,G9158,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,80.39,8.55,182.7,,,,,,CI At least 1% but less than 20% impaired,G9158,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,29.13,3.6,69.6,,,,,,CH 0% impaired,G9158,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,29.13,6.03,69.6,,,,,,CN 100% impaired,G9186,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,32.82,6.74,92.02,,,,,,CM At least 80% but less than 100% impaired,G9186,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,25.87,2.99,62.24,,,,,,CL At least 60% but less than 80% impaired,G9186,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,20.33,2.99,48.11,,,,,,CK At least 40% but less than 60% impaired,G9186,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.06,6.79,100.4,,,,,,CJ At least 20% but less than 40% impaired,G9186,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,0,2.84,108.1,,,,,,CI At least 1% but less than 20% impaired,G9186,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,0,6.8,52.43,,,,,,CH 0% impaired,G9186,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.07,7.27,172,,,,,,CN 100% impaired,G9176,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,69.3,45.82,378.9,,,,,,CM At least 80% but less than 100% impaired,G9176,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,59.85,29.48,105,,,,,,CL At least 60% but less than 80% impaired,G9176,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.83,6.15,4344.87,,,,,,CK At least 40% but less than 60% impaired,G9176,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,265.43,39.27,311.42,,,,,,CJ At least 20% but less than 40% impaired,G9176,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,47.77,19.15,448.97,,,,,,CI At least 1% but less than 20% impaired,G9176,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,187.13,68.61,524.17,,,,,,CH 0% impaired,G9176,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,44.4,4.51,1156.79,,,,,,CN 100% impaired,G9175,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,83.64,29.4,2785.69,,,,,,CM At least 80% but less than 100% impaired,G9175,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,20.33,13.42,41.31,,,,,,CL At least 60% but less than 80% impaired,G9175,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,61.05,40.84,136.8,,,,,,CK At least 40% but less than 60% impaired,G9175,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],101.5,76.13,76.13,55.06,37.78,80.08,,,,,,CJ At least 20% but less than 40% impaired,G9175,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,35.11,23.51,98.36,,,,,,CI At least 1% but less than 20% impaired,G9175,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,206.7,140.59,428.4,,,,,,CH 0% impaired,G9175,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,73.87,40.84,154.11,,,,,,CN 100% impaired,G9159,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,102.56,39.1,434.06,,,,,,CM At least 80% but less than 100% impaired,G9159,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,217.97,61.48,2109.82,,,,,,CL At least 60% but less than 80% impaired,G9159,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,238.88,50,3116.59,,,,,,CK At least 40% but less than 60% impaired,G9159,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,533.58,62.92,1098.7,,,,,,CJ At least 20% but less than 40% impaired,G9159,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,5.5,5.5,14.67,,,,,,CI At least 1% but less than 20% impaired,G9159,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,3.54,0.68,2868.2,,,,,,CH 0% impaired,G9159,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,5.5,5.5,1162.88,,,,,,CN 100% impaired,G9161,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-FEP A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,3.67,1.72,16.28,,,,,,CM At least 80% but less than 100% impaired,G9161,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.85,2.44,580.94,,,,,,CL At least 60% but less than 80% impaired,G9161,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,142.16,20.71,250.4,,,,,,CK At least 40% but less than 60% impaired,G9161,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,CJ At least 20% but less than 40% impaired,G9161,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,0,14.4,297.7,,,,,,CI At least 1% but less than 20% impaired,G9161,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,48.53,9.42,73.71,,,,,,CH 0% impaired,G9161,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43,2.66,76.2,,,,,,CN 100% impaired,G9160,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,36.74,5.81,65.1,,,,,,CM At least 80% but less than 100% impaired,G9160,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.19,2.66,8.7,,,,,,CL At least 60% but less than 80% impaired,G9160,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,79.68,9.87,141.2,,,,,,CK At least 40% but less than 60% impaired,G9160,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,CJ At least 20% but less than 40% impaired,G9160,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.55,6.15,4344.87,,,,,,CI At least 1% but less than 20% impaired,G9160,0440,,0.01,0.0075,0.0075
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,531.45,62.92,1098.7,,,,,,CH 0% impaired,G9160,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,104.9,20.71,250.4,,,,,,CN 100% impaired,G9162,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,0,5.03,33.1,,,,,,CM At least 80% but less than 100% impaired,G9162,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,CL At least 60% but less than 80% impaired,G9162,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,0,18.04,43.1,,,,,,CK At least 40% but less than 60% impaired,G9162,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,0,18.04,43.1,,,,,,CJ At least 20% but less than 40% impaired,G9162,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,0,4.42,42.84,,,,,,CI At least 1% but less than 20% impaired,G9162,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,0,5.2,40.9,,,,,,CH 0% impaired,G9162,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,0,3.99,48.28,,,,,,CN 100% impaired,G9164,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,0,5.07,94.54,,,,,,CM At least 80% but less than 100% impaired,G9164,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,0,13.86,33.1,,,,,,CL At least 60% but less than 80% impaired,G9164,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,0,4.75,40.9,,,,,,CK At least 40% but less than 60% impaired,G9164,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,0,7.89,28.7,,,,,,CJ At least 20% but less than 40% impaired,G9164,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,CI At least 1% but less than 20% impaired,G9164,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,0,18.48,44.1,,,,,,CH 0% impaired,G9164,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,0,4.35,39.58,,,,,,CN 100% impaired,G9163,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,0,5.83,44.1,,,,,,CM At least 80% but less than 100% impaired,G9163,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,0,4.02,32.1,,,,,,CL At least 60% but less than 80% impaired,G9163,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,90747,Hepatitis B vaccine for injection into muscle of dialysis or immunosuppressed patient (4 dose schedule) [HCPCS 90747],396.7,297.53,297.53,122.98,122.98,396.7,,,,,,CK At least 40% but less than 60% impaired,G9163,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,305.08,105.86,1389.2,,,,,,CJ At least 20% but less than 40% impaired,G9163,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,CI At least 1% but less than 20% impaired,G9163,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,CH 0% impaired,G9163,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,258.3,107.28,315.01,,,,,,CN 100% impaired,G9171,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],564.9,423.68,423.68,339.56,336.44,339.56,,,,,,CM At least 80% but less than 100% impaired,G9171,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,362.31,231.95,364.61,,,,,,CL At least 60% but less than 80% impaired,G9171,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,G0010,Admin hepatitis b vaccine [HCPCS G0010],14.4,10.8,10.8,4.25,4.25,4.25,,,,,,CK At least 40% but less than 60% impaired,G9171,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,0,6.13,13.93,,,,,,CJ At least 20% but less than 40% impaired,G9171,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,0,1.1,3.07,,,,,,CI At least 1% but less than 20% impaired,G9171,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0,0.63,1.44,,,,,,CH 0% impaired,G9171,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,0,4,9.09,,,,,,CN 100% impaired,G9173,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,2271.28,393.52,2894.06,,,,,,CM At least 80% but less than 100% impaired,G9173,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,8.8,2.44,580.94,,,,,,CL At least 60% but less than 80% impaired,G9173,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,541.46,494.34,1384.62,,,,,,CK At least 40% but less than 60% impaired,G9173,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,658.81,137.3,1347.57,,,,,,CJ At least 20% but less than 40% impaired,G9173,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,104.9,20.71,250.4,,,,,,CI At least 1% but less than 20% impaired,G9173,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,152.63,28.74,271.3,,,,,,CH 0% impaired,G9173,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,126.58,94.25,177.23,,,,,,CN 100% impaired,G9172,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,148.6,109.96,166.13,,,,,,CM At least 80% but less than 100% impaired,G9172,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,718.2,137.3,1124.55,,,,,,CL At least 60% but less than 80% impaired,G9172,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1412.4,1059.3,1059.3,766.71,272.21,898.39,,,,,,CK At least 40% but less than 60% impaired,G9172,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,127.42,4.45,148.78,,,,,,CJ At least 20% but less than 40% impaired,G9172,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72080,Spinal x-ray of junction of middle and lower spine (2 views) [HCPCS 72080],121.3,90.98,90.98,68.69,68.69,123.34,,,,,,CI At least 1% but less than 20% impaired,G9172,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,127.42,94.25,222.4,,,,,,CH 0% impaired,G9172,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,127.42,25.73,191.25,,,,,,CN 100% impaired,G8990,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,122.09,18.85,148.78,,,,,,CM At least 80% but less than 100% impaired,G8990,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,127.42,29.4,177.53,,,,,,CL At least 60% but less than 80% impaired,G8990,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,94.25,31.41,166.13,,,,,,CK At least 40% but less than 60% impaired,G8990,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1547.7,180.22,3324.06,,,,,,CJ At least 20% but less than 40% impaired,G8990,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,196.37,137.3,401.67,,,,,,CI At least 1% but less than 20% impaired,G8990,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],580,435,435,328.45,55.14,328.45,,,,,,CH 0% impaired,G8990,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,87.38,8.49,161,,,,,,CN 100% impaired,G8981,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,0,41.68,551.29,,,,,,CM At least 80% but less than 100% impaired,G8981,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,8.87,355.2,,,,,,CL At least 60% but less than 80% impaired,G8981,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,84.02,11.25,148.9,,,,,,CK At least 40% but less than 60% impaired,G8981,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,0,14.4,297.7,,,,,,CJ At least 20% but less than 40% impaired,G8981,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,36.04,9.42,73.71,,,,,,CI At least 1% but less than 20% impaired,G8981,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,31.9,2.66,76.2,,,,,,CH 0% impaired,G8981,0420,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,40.22,5.44,96,,,,,,CN 100% impaired,G9174,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,163.71,30.08,290.1,,,,,,CM At least 80% but less than 100% impaired,G9174,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,27.28,5.81,65.1,,,,,,CL At least 60% but less than 80% impaired,G9174,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,52.23,12.67,98.39,,,,,,CK At least 40% but less than 60% impaired,G9174,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,48.53,8.16,104.31,,,,,,CJ At least 20% but less than 40% impaired,G9174,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,110.64,9.72,190.22,,,,,,CI At least 1% but less than 20% impaired,G9174,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,44.35,5,105.9,,,,,,CH 0% impaired,G9174,0440,,0.01,0.0075,0.0075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,160.91,32.98,268.8,,,,,,99281 - Level 1,99281,0450,,131.3,98.475,98.475
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,73.42,7.58,134.6,,,,,,99282 - ED Tech Level 2,99282,0450,,244.8,183.6,183.6
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,76.58,14.11,134.34,,,,,,99283 - ED Tech Level 3,99283,0450,,384.9,288.675,288.675
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,65.16,14.41,153.94,,,,,,99284 - ED Tech Level 4,99284,0450,,570.1,427.575,427.575
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,59.14,9.87,141.2,,,,,,99285 - ED Tech Level 5,99285,0450,,936.1,702.075,702.075
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,"Critical Care, First Hour 99291",99291,0450,,"1,027.6",770.7,770.7
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86704,Lab analysis to identify Hepatitis B core antibodies (IgG and IgM) [HCPCS 86704],155.5,116.63,116.63,65.16,65.16,153.94,,,,,,"Critical Care, Addl 30 Min 99292",99292,0450,,261.4,196.05,196.05
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86706,Lab analysis to identify Hepatitis B surface antibodies [HCPCS 86706],113.7,85.28,85.28,42.06,42.06,47.61,,,,,,XR Spine Thoracolumbar 1 View,72020,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,93.32,11.99,222.7,,,,,,0312 PATHOL/HYSTOL,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,32.82,6.74,92.02,,,,,,CPR – Cardiopulmonary Resuscitation,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,25.87,2.99,62.24,,,,,,Rhythm Strip,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,20.33,2.99,48.11,,,,,,Miscellaneous Lab Test,,0300,,0,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,51.75,11.93,144.95,,,,,,Regional Block,,0370,,0,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,80.48,9.2,112.32,,,,,,US Breast Complete Left,76641,0402,,421.2,315.9,315.9
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.06,6.79,100.4,,,,,,US Breast Complete Right,76641,0402,,421.2,315.9,315.9
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,45.28,2.84,108.1,,,,,,US Breast Limited Left,76642,0402,,323.1,242.325,242.325
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,10.38,6.8,52.43,,,,,,US Breast Limited Right,76642,0402,,323.1,242.325,242.325
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.07,7.27,172,,,,,,SN Free Text Item,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87340,Lab analysis by immunoassay (ELISA) to identify Hepatitis B surface antigen [HCPCS 87340],105.9,79.43,79.43,44.35,10.5,44.35,,,,,,No Preference Card Available,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,88.64,8.17,155.5,,,,,,C-Arm Mini,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,46.2,37.79,110.3,,,,,,Minor Set,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,69.3,45.82,378.9,,,,,,Retractor Gelpi,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,0,20.12,77.89,,,,,,Scissors Micro Laparoscopic,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,51.3,6.15,4344.87,,,,,,XR Femur 1 View Left,73551,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,254.39,39.27,311.42,,,,,,XR Femur 1 View Right,73551,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,35.11,19.15,448.97,,,,,,XR Femur 2 Views Left,73552,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,187.13,28.6,1161.38,,,,,,XR Femur 2 Views Right,73552,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,40.66,16.26,2475.42,,,,,,XR Hip 1 View w/ AP Pelvis Left,73501,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,242.42,68.61,524.17,,,,,,XR Hip 1 View w/ AP Pelvis Right,73501,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,32.82,4.51,1156.79,,,,,,XR Hip 2-3 Views Left,73502,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,83.64,29.4,2785.69,,,,,,XR Hip 2-3 Views Right,73502,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,16.63,12.56,48.28,,,,,,XR Hip 2-3 Views w/AP Pelvis Left,73502,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,63.71,40.84,136.8,,,,,,XR Hip 2-3 Views w/AP Pelvis Right,73502,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,69.83,40.84,143.78,,,,,,XR Hips 2 Views w/AP Pelvis Bilat,73521,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,47.46,23.51,98.36,,,,,,XR Spine Scoliosis 1 View,72081,0320,,225,168.75,168.75
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,208.05,140.59,428.4,,,,,,XR Spine Scoliosis 2-3 Views,72082,0320,,506.1,379.575,379.575
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,Wet Mount POC,87210,0521,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,102.56,39.1,434.06,,,,,,H Pylori POC,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,208.91,61.48,2109.82,,,,,,US Carotid Duplex Unilat/Limited,93882,0921,,713.4,535.05,535.05
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,238.88,50,3116.59,,,,,,0001 TOTAL CHARGE,,0999,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,392.26,62.92,1098.7,,,,,,0022 SNF PPS (RUG),,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,4.89,3.22,2266.54,,,,,,0023 HHS PPS (HRG),,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2.75,0.68,2868.2,,,,,,0024 IRF PPS (CMG),,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,11,2.1,2819.66,,,,,,0100 ALL INCL R&B/ANC,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J1630,Haloperidol injection [HCPCS J1630],25,18.75,18.75,11,1.08,29.34,,,,,,0101 ALL INCL R&B,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,11,5.5,1162.88,,,,,,0110 ROOM-BOARD/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,11,7.08,29.34,,,,,,0111 MED-SUR-GY/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,11,3.15,30.39,,,,,,0112 OB/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,5.5,0.95,3583.7,,,,,,0113 PEDS/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,12.8,5.49,347.63,,,,,,0114 PSYCH/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,3.64,1.29,348.28,,,,,,0115 HOSPICE/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,8.8,1.66,23.47,,,,,,0116 DETOX/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,1.76,23.48,,,,,,0117 ONCOLOGY/PVT,,,,,,
HCSC-BCBS OF TX-OTHER A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,638.07,167.53,728.8,,,,,,0118 REHAB/PVT,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,351.42,214.38,2255.8,,,,,,0119 OTHER/PVT,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Dialysis Clinic,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,290.97,242.91,1540,,,,,,0120 ROOM-BOARD/SEMI,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Dialysis Clinic,Professional,Outpatient,90962,Dialysis services by physician with 1 visit per month (20 years of age and older) [HCPCS 90962],1455.3,1091.48,1091.48,199.16,199.16,1320,,,,,,0121 MED-SUR-GY/2BED,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,351.42,214.38,2255.8,,,,,,0122 OB/2BED,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,97.06,59.92,194.57,,,,,,0123 PEDS/2BED,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,0124 PSYCH/2BED,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,68.96,45.48,91.29,,,,,,0125 HOSPICE/2BED,,,,,,
HCSC-BCBS OF TX-OTHER B ONLY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.82,59.99,274.04,,,,,,0126 DETOX/2BED,,,,,,
HEALTH CARE SERV - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,0127 ONCOLOGY/2BED,,,,,,
HEALTH CARE SERV - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,0128 REHAB/2BED,,,,,,
HEALTH CARE SERV - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,0129 OTHER/2BED,,,,,,
HEALTH CARE SERV - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,195.94,51.31,199.63,,,,,,0130 ROOM-BOARD/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],3533.3,2649.98,2649.98,0,8.8,16.21,,,,,,0131 MED-SUR-GY/3&4,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,86.56,86.56,406.84,,,,,,0132 OB/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,149.3,149.3,149.3,,,,,,0133 PEDS/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,151.19,151.19,151.19,,,,,,0134 PSYCH/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,149.68,149.68,149.68,,,,,,0135 HOSPICE/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],225,168.75,168.75,24.07,24.07,24.07,,,,,,0136 DETOX/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",2510.5,1882.88,1882.88,247.56,247.56,247.56,,,,,,0137 ONCOLOGY/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,7.21,7.21,246,,,,,,0138 REHAB/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],283.5,212.63,212.63,9.98,9.98,223.68,,,,,,0139 OTHER/3&4BED,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,11.4,11.4,,,,,,0140 ROOM-BOARD/PVT/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],72.5,54.38,54.38,0,3.22,57.2,,,,,,0141 MED-SUR-GY/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,4.44,4.44,4.44,,,,,,0142 OB/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,4.7,4.7,7.01,,,,,,0143 PEDS/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,6.71,6.71,12.67,,,,,,0144 PSYCH/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",84,63,63,5.31,5.31,66.28,,,,,,0145 HOSPICE/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],69.6,52.2,52.2,2.69,2.69,69.6,,,,,,0146 DETOX/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],69.6,52.2,52.2,4.1,4.1,4.1,,,,,,0147 ONCOLOGY/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],116.6,87.45,87.45,7.4,7.4,100.98,,,,,,0148 REHAB/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",301.4,226.05,226.05,0,132.62,231.48,,,,,,0149 OTHER/DLX,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",79.4,59.55,59.55,0,30.65,30.65,,,,,,0150 ROOM-BOARD/WARD,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],657.1,492.83,492.83,158.84,158.84,722.74,,,,,,0151 MED-SUR-GY/WARD,,,,,,
HEALTH PLAN OF NEVADA - Commercial-Mut Defined,,Professional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,18.6,18.6,18.6,,,,,,0152 OB/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,0,5.03,33.1,,,,,,0153 PEDS/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,0154 PSYCH/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,0,18.04,43.1,,,,,,0155 HOSPICE/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,0,18.04,43.1,,,,,,0156 DETOX/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,0,4.42,42.84,,,,,,0157 ONCOLOGY/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,0,5.2,40.9,,,,,,0158 REHAB/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,0,3.99,48.28,,,,,,0159 OTHER/WARD,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,0,5.07,94.54,,,,,,0160 R&B,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,0,13.86,33.1,,,,,,0164 R&B/STERILE,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,0,4.75,40.9,,,,,,0167 R&B/SELF,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,0,7.89,28.7,,,,,,0169 R&B/OTHER,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,0170 NURSERY,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,0,18.48,44.1,,,,,,0171 NURSERY/LEVEL I,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,0,4.35,39.58,,,,,,0172 NURSERY/LEVEL II,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,0,5.83,44.1,,,,,,0173 NURSERY/LEVEL III,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,0,4.02,32.1,,,,,,0174 NURSERY/LEVEL IV,,,,,,
HEALTHCARE PARTNERS NEVADA - Commercial-HMO,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,195.18,105.86,1389.2,,,,,,0179 NURSERY/OTHER,,,,,,
HEALTHEZ - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,0180 LEAVE OF ABSENCE,,,,,,
HEALTHEZ - Commercial-PPO,,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,109.78,91.42,145.6,,,,,,0182 LOA/PT CONV,,,,,,
HEALTHEZ - Commercial-PPO,,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0,0.08,6.58,,,,,,0183 LOA/THERAPEUTIC,,,,,,
HEALTHEZ - Commercial-PPO,,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,0184 LOA/ICF/MR,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,0185 LOA/NURSE HOME,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,0189 LOA/OTHER,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,90750,Shingles vaccine for injection into muscle [HCPCS 90750],446.6,334.95,334.95,161.36,161.36,446.6,,,,,,0190 SUBACUTE,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,0191 SUBACUTE/LEVEL I,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,0192 SUBACUTE/LEVEL II,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,114.08,70,166.6,,,,,,0193 SUBACUTE/LEVEL III,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,1.39,1.39,26.3,,,,,,0194 SUBACUTE/LEVEL IV,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,J1030,Methylprednisolone 40 mg inj [HCPCS J1030],26.3,19.73,19.73,4.94,4.94,5.92,,,,,,0199 SUBACUTE/OTHER,,,,,,
HEALTHSMART BENE - Commercial-PPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,0200 INTENSIVE CARE,,,,,,
HEALTHSMART BENE - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,120.51,62.11,380.62,,,,,,0201 ICU/SURGICAL,,,,,,
HEALTHSMART BENE - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,0202 ICU/MEDICAL,,,,,,
"HEALTHSMART BENEFITS SOLUTIONS, INC. - Commercial-PPO",,Professional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel procedure with endoscope [HCPCS 00813]",139,104.25,104.25,556,5.44,556,,,,,,0203 ICU/PEDS,,,,,,
"HEALTHSMART BENEFITS SOLUTIONS, INC. - Commercial-PPO",,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1340.7,1005.53,1005.53,93.58,65.83,226.6,,,,,,0204 ICU/PSTAY,,,,,,
"HEALTHSMART BENEFITS SOLUTIONS, INC. - Commercial-PPO",,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,283.81,192.01,343.2,,,,,,0206 POST ICU,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,7.24,7.24,496.86,,,,,,0207 ICU/BURN CARE,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,11.87,8.17,155.5,,,,,,0208 ICU/TRAUMA,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,11.68,11.68,116.85,,,,,,0209 ICU/OTHER,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,14.12,14.12,74.6,,,,,,0210 CORONARY CARE,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,58.97,58.97,116.37,,,,,,0211 CCU/MYO INFARC,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,0212 CCU/PULMONARY,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,29.48,29.48,105,,,,,,0213 CCU/TRANSPLANT,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,130.6,39.1,434.06,,,,,,0214 POST CCU,,,,,,
AETNA BETTER HEALTH - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,135.06,61.48,2109.82,,,,,,0219 CCU/OTHER,,,,,,
HEALTHY BLUE - Medicaid,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,0,12.82,82,,,,,,0220 SPECIAL CHARGES,,,,,,
HEALTHY BLUE - Medicaid,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,0,1.28,46.3,,,,,,0221 ADMIT CHARGE,,,,,,
HEALTHY BLUE - Medicaid,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,0,45.56,141.93,,,,,,0222 TECH SUPPORT CHG,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,0223 UR CHARGE,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,0,137.3,1347.57,,,,,,0224 LATE DISCH/MED NEC,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,70496,CTA scan of head blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70496],1345.1,1008.83,1008.83,0,563.64,889.41,,,,,,0229 OTHER SPEC CHG,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,70498,CTA scan of neck blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70498],1345.1,1008.83,1008.83,0,294.63,889.41,,,,,,0230 NURSING INCREM,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,0,20.71,250.4,,,,,,0231 NUR INCR/NURSERY,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,0,8.87,355.2,,,,,,0232 NUR INCR/OB,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,0,2.66,76.2,,,,,,0233 NUR INCR/ICU,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,0,2.66,8.7,,,,,,0234 NUR INCR/CCU,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,9.87,141.2,,,,,,0235 NUR INCR/HOSPICE,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,0,6,88.2,,,,,,0239 NUR INCR/OTHER,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,0,3.6,69.6,,,,,,0240 ALL INCL ANCIL,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,0,6.03,69.6,,,,,,0241 ALL INCL BASIC,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,0,45.82,378.9,,,,,,0242 ALL INCL COMP,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,0243 ALL INCL SPECIAL,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,0,12.56,48.28,,,,,,0249 INCL ANCIL/OTHER,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,0,50,3116.59,,,,,,0250 PHARMACY,,,,,,
HEALTHY BLUE - Medicaid,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,0.11,0.11,332.88,,,,,,0251 DRUGS/GENERIC,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,293.43,35.11,337.46,,,,,,0252 DRUGS/NONGENERIC,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,310.23,70.45,319.43,,,,,,0253 DRUGS/TAKEHOME,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,315.01,107.28,315.01,,,,,,0254 DRUGS/INCIDENT ODX,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.73,2.44,580.94,,,,,,0255 DRUGS/INCIDENT RAD,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,663.7,494.34,1384.62,,,,,,0256 DRUGS/EXPERIMT,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,70200,"Eye socket x-ray to evaluate injury, foreign bodies, or tumors (complete study, minimum of 4 views) [HCPCS 70200]",225,168.75,168.75,128.25,128.25,128.25,,,,,,0257 DRGS/NONPSCRPT,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,896.15,137.3,1347.57,,,,,,0258 IV SOLUTIONS,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,141.8,20.71,250.4,,,,,,0259 DRUGS/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,113.65,28.74,271.3,,,,,,0260 IV THERAPY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,128.25,33.08,182.07,,,,,,0261 IV THER/INFSN PUMP,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,90.85,8.49,161,,,,,,0262 IV THER/PHARM/SVC,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,0263 IV THER/DRUG/SUPPLY DELV,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,84.02,11.25,148.9,,,,,,0264 IV THER/SUPPLIES,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,167.99,14.4,297.7,,,,,,0269 IV THER/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,48.53,9.42,73.71,,,,,,0270 MED-SUR SUPPLIES,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43,2.66,76.2,,,,,,0271 NON-STER SUPPLY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,36.37,5.81,65.1,,,,,,0272 STERILE SUPPLY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,56.03,11.55,98.31,,,,,,0273 TAKEHOME SUPPLY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,0,32.34,465.3,,,,,,0274 PROSTH/ORTH DEVICE,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,66.65,11.45,112.4,,,,,,0275 PACE MAKER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.14,2.66,8.7,,,,,,0276 INTROC LENS,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,65.4,8.16,104.31,,,,,,0277 O2/TAKEHOME,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,109.53,9.72,190.22,,,,,,0278 SUPPLY/IMPLANTS,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,59.76,5,105.9,,,,,,0279 SUPPLY/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,40.67,5.63,72.8,,,,,,0280 ONCOLOGY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,157.69,32.98,268.8,,,,,,0289 ONCOLOGY/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,73.42,7.58,134.6,,,,,,0290 MED EQUIP/DURAB,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,76.58,14.11,134.34,,,,,,0291 MED EQUIP/RENT,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,78.87,9.87,141.2,,,,,,0292 MED EQUIP/NEW,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],44.1,33.08,33.08,5.59,2.41,10,,,,,,0293 MED EQUIP/USED,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],12.2,9.15,9.15,5.59,2.41,10,,,,,,0294 MED EQUIP/SUPPLIES/DRUGS,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.26,6,88.2,,,,,,0299 MED EQUIP/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,15.71,5.43,37.5,,,,,,0300 LABORATORY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,108.29,8.55,182.7,,,,,,0301 LAB/CHEMISTRY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,39.27,3.6,69.6,,,,,,0302 LAB/IMMUNOLOGY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,39.27,6.03,69.6,,,,,,0303 LAB/RENAL HOME,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,43.8,6.74,92.02,,,,,,0304 LAB/NR DIALYSIS,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,34.77,2.99,62.24,,,,,,0305 LAB/HEMATOLOGY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,27.34,2.99,48.11,,,,,,0306 LAB/BACT-MICRO,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,68.99,11.93,144.95,,,,,,0307 LAB/UROLOGY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,56.66,6.79,100.4,,,,,,0309 LAB/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,61,2.84,108.1,,,,,,0310 PATHOLOGY LAB,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,14,6.8,52.43,,,,,,0311 PATHOL/CYTOLOGY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,97.06,7.27,172,,,,,,0314 PATHOL/BIOPSY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,88.64,8.17,155.5,,,,,,0319 PATHOL/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,94.28,45.82,378.9,,,,,,0320 DX X-RAY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.38,6.15,4344.87,,,,,,0321 DX X-RAY/ANGIO,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,35.11,16.49,98.36,,,,,,0322 DX X-RAY/ARTH,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,35.11,19.15,448.97,,,,,,0323 DX X-RAY/ARTER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,43.43,16.26,2475.42,,,,,,0324 DX X-RAY/CHEST,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,199.72,68.61,524.17,,,,,,0329 DX X-RAY/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,43.43,20.72,3197.1,,,,,,0330 RX X-RAY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,69.04,4.51,1156.79,,,,,,0331 CHEMOTHER/INJ,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,132.62,29.4,2785.69,,,,,,0332 CHEMOTHER/ORAL,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.48,12.56,48.28,,,,,,0333 RADIATION RX,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,15.71,10.24,44.01,,,,,,0335 CHEMOTHERP-IV,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,63.71,40.84,136.8,,,,,,0339 RX X-RAY/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,208.05,140.59,428.4,,,,,,0340 NUCLEAR MEDICINE,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,138.63,39.1,434.06,,,,,,0341 NUC MED/DX,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,324.96,50,3116.59,,,,,,0342 NUC MED/RX,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,530.12,62.92,1098.7,,,,,,0343 Diagnostic radiopharmaceuticals,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,13.67,5.83,3301.98,,,,,,0344 Therapeutic radiopharmaceuticals,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,10.16,7.4,19.63,,,,,,0349 NUC MED/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,7.08,7.08,29.34,,,,,,0350 CT SCAN,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.08,0.95,3583.7,,,,,,0351 CT SCAN/HEAD,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,494.43,167.53,728.8,,,,,,0352 CT SCAN/BODY,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,92.7,52.53,206.9,,,,,,0359 CT SCAN/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,129.79,81.71,178.67,,,,,,0360 OR SERVICES,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,130.46,95.05,222.03,,,,,,0361 OR/MINOR,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.03,22.37,41.75,,,,,,0362 OR/ORGAN TRANS,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,69.53,39.55,134.08,,,,,,0367 OR/KIDNEY TRANS,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,36.7,31.68,51.15,,,,,,0369 OR/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,67.86,45.48,91.29,,,,,,0370 ANESTHESIA,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,124.75,114.76,176.55,,,,,,0371 ANESTHE/INCIDENT RAD,,,,,,
HEARTLAND NATIONAL LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.58,59.99,274.04,,,,,,0372 ANESTHE/INCIDENT ODX,,,,,,
HEARTLAND NATIONAL LIFE INSURANCE COMPANY - Commercial-Mut Defined,Other Professional Setting,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,0,107.28,315.01,,,,,,0374 ANESTHE/ACUPUNC,,,,,,
HEARTLAND NATIONAL LIFE INSURANCE COMPANY - Commercial-Mut Defined,Other Professional Setting,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,178.67,81.71,178.67,,,,,,0379 ANESTHE/OTHER,,,,,,
HEARTLAND NATIONAL LIFE INSURANCE COMPANY - Commercial-Mut Defined,Other Professional Setting,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,222.03,95.05,222.03,,,,,,0380 BLOOD,,,,,,
HEARTLAND NATIONAL LIFE INSURANCE COMPANY - Commercial-Mut Defined,Other Professional Setting,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,134.08,39.55,134.08,,,,,,0381 BLOOD/PKD RED,,,,,,
HEARTLAND NATIONAL LIFE INSURANCE COMPANY - Commercial-Mut Defined,Other Professional Setting,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,274.04,59.99,274.04,,,,,,0382 BLOOD/WHOLE,,,,,,
HUMANA - Commercial-HMO,Hospital,Institutional,Inpatient,645,Endocrine disorders without complications,286.8,215.1,215.1,57.07,43.38,118.4,,,,,,0383 BLOOD/PLASMA,,,,,,
HUMANA - Commercial-PPO,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,0,106.96,3862,,,,,,0384 BLOOD/PLATELETS,,,,,,
HUMANA - Commercial-PPO,Hospital,Institutional,Inpatient,639,Diabetes without complications,136.9,102.68,102.68,61.05,16.31,2312.51,,,,,,0385 BLOOD/LEUCOCYTES,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,19.9,2.07,19.9,,,,,,0386 BLOOD/COMPONENTS,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,0387 BLOOD/DERIVATIVES,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,111.4,45.56,141.93,,,,,,0389 BLOOD/OTHER,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,145.6,91.42,145.6,,,,,,0390 BLOOD/STOR-PROC,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,105.9,62.38,245.75,,,,,,0391 BLOOD/ADMIN,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,6.58,0.08,6.58,,,,,,0399 BLOOD/OTHER STOR,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,26.3,5.44,26.3,,,,,,0400 IMAGE SERVICE,,,,,,
HUMANA INC - Commercial-PPO,Clinic,Professional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],26.3,19.73,19.73,26.3,1.31,26.3,,,,,,0401 DIAG MAMMOGRAPHY,,,,,,
HUMANA INC. - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,0,39.1,434.06,,,,,,0402 ULTRASOUND,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,33.1,5.03,33.1,,,,,,0403 SCRN MAMMOGRAPHY,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,28.7,19.16,56.63,,,,,,0404 PET SCAN,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,43.1,18.04,43.1,,,,,,0409 OTHER IMAG SVS,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,43.1,18.04,43.1,,,,,,0410 RESPIRATORY SVC,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,30.9,4.42,42.84,,,,,,0412 INHALATION SVC,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,40.9,5.2,40.9,,,,,,0413 HYPERBARIC 02,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,46.3,3.99,48.28,,,,,,0419 OTHER RESPIR SVS,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,30.9,5.07,94.54,,,,,,0420 PHYSICAL THERAPY,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,33.1,13.86,33.1,,,,,,0421 PHYS THERP/VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,40.9,4.75,40.9,,,,,,0422 PHYS THERP/HOUR,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,28.7,7.89,28.7,,,,,,0423 PHYS THERP/GROUP,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,36.5,15.27,36.5,,,,,,0424 PHYS THERP/EVAL,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,44.1,18.48,44.1,,,,,,0429 OTHER PHYS THERP,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,33.1,4.35,39.58,,,,,,0430 OCCUPATION THER,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,44.1,5.83,44.1,,,,,,0431 OCCUP THERP/VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,32.1,4.02,32.1,,,,,,0432 OCCUP THERP/HOUR,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,90747,Hepatitis B vaccine for injection into muscle of dialysis or immunosuppressed patient (4 dose schedule) [HCPCS 90747],396.7,297.53,297.53,396.7,122.98,396.7,,,,,,0433 OCCUP THERP/GROUP,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,1389.2,105.86,1389.2,,,,,,0434 OCCUP THERP/EVAL,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],230.5,172.88,172.88,262.94,80.15,262.94,,,,,,0439 OTHER OCCUP THER,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,265.5,131.45,310.8,,,,,,0440 SPEECH PATHOL,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,0,266.1,323.65,,,,,,0441 SPEECH PATH/VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,265.5,35.11,337.46,,,,,,0442 SPEECH/PATH/HOUR,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,265.5,70.45,319.43,,,,,,0443 SPEECH PATH/GROUP,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,265.5,107.28,315.01,,,,,,0444 SPEECH PATH/EVAL,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,265.5,113,283.23,,,,,,0449 OTHER SPEECH PAT,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99306,Initial nursing facility visit by admitting physician for problem of high severity (typically 45 minutes per day) [HCPCS 99306],759.7,569.78,569.78,265.5,231.95,368,,,,,,0450 EMERG ROOM,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,99310,Subsequent nursing facility visit for patient that is unstable or may have develped a major new problem requiring immediate physician attention (typically 35 minutes per day) [HCPCS 99310],617.4,463.05,463.05,260.49,260.49,344.18,,,,,,0451 ER/EMTALA,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,G0010,Admin hepatitis b vaccine [HCPCS G0010],14.4,10.8,10.8,0,4.25,4.25,,,,,,0452 ER/BEYOND EMTALA,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Institutional,Outpatient,G0438,"Ppps, initial visit [HCPCS G0438]",68.4,51.3,51.3,265.5,113,283.23,,,,,,0456 URGENT CARE,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.19,5.19,5.3,,,,,,0459 OTHER EMER ROOM,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,107.95,91.42,145.6,,,,,,0460 PULMONARY FUNC,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,159.65,140.39,202.54,,,,,,0469 OTHER PULMON FUNC,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.95,13.55,72.8,,,,,,0470 AUDIOLOGY,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,88.65,62.38,245.75,,,,,,0471 AUDIOLOGY/DX,,,,,,
HUMANA INC. - Medicare-HMO,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,67.72,65.1,68.4,,,,,,0472 AUDIOLOGY/RX,,,,,,
HUMANA INC. - Medicare-HMO,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,343.3,214.38,2255.8,,,,,,0479 OTHER AUDIOLOGY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,177,Respiratory infections and inflammations with major complications,52200.75,39150.56,39150.56,11586,11586,11586,,,,,,0480 CARDIOLOGY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,194,Pneumonia with complications,29394.9,22046.18,22046.18,5793,2771.17,5793,,,,,,0481 CARDIAC CATH LAB,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,208,Ventilator support for 4 days or less,12909.37,9682.03,9682.03,21241,21241,21241,,,,,,0482 STRESS TEST,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,291,Heart Failure with major complications,23327.8,17495.85,17495.85,3830.58,286.98,3830.58,,,,,,0483 ECHOCARDIOLOGY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,293,Heart failure & shock without complications,11691.95,8768.96,8768.96,7724,272.06,7724,,,,,,0489 OTHER CARDIOL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,352,Inguinal & femoral hernia procedures without complications,9486.13,7114.6,7114.6,1931,1931,1931,,,,,,0490 AMBUL SURG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,377,G.I. hemorrhage with major complications,23903.92,17927.94,17927.94,3862,3862,3862,,,,,,0499 OTHER AMBUL SURG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,379,G.I. hemorrhage without complications,4664.75,3498.56,3498.56,3830.58,272.1,3830.58,,,,,,0500 OUTPATIENT SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,554,Bone diseases & arthropathies without major complications,2172.28,1629.21,1629.21,0,10.47,679.97,,,,,,0509 OUTPATIENT/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,559,"Aftercare, musculoskeletal system & connective tissue with major complications",24506.94,18380.21,18380.21,33460,33460,33460,,,,,,0510 CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,3862,106.96,3862,,,,,,0511 CHRONIC PAIN CL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,637,Diabetes with major complications,6822.3,5116.73,5116.73,31787,103.4,31787,,,,,,0512 DENTAL CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,0,16.31,81.11,,,,,,0513 PSYCH CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,5253.83,3940.37,3940.37,0,13.56,1256.28,,,,,,0514 OB-GYN CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,0,5.83,3301.98,,,,,,0515 PEDS CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,461.27,167.53,728.8,,,,,,0516 URGENT CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Inpatient,U0004,"2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r [HCPCS U0004]",89.3,66.98,66.98,43.47,39.29,43.47,,,,,,0517 FAMILY CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,0,55,3102.09,,,,,,0519 OTHER CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,1329,393.52,2894.06,,,,,,0520 FREESTAND CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,125,55,125,,,,,,0521 RURAL/CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,122.5,55,166.67,,,,,,0522 RURAL/HOME,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,125,55,125,,,,,,0523 FR/STD FAMILY CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,21012,Tissue tumor removal beneath the skin of face and scalp (2 cm or greater) [HCPCS 21012],5879.56,4409.67,4409.67,2436.61,2436.61,2436.61,,,,,,0526 FR/STD URGENT CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,26160,Tendon lesion removal from finger or hand [HCPCS 26160],5424.76,4068.57,4068.57,2717.8,2717.8,2717.8,,,,,,0529 OTHER FR/STD CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,20,2.44,580.94,,,,,,0530 OSTEOPATH SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,0,494.34,1384.62,,,,,,0531 OSTEOPATH RX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,36600,Collection of blood specimen from arterial puncture for diagnosis [HCPCS 36600],293.6,220.2,220.2,0,39.78,171.67,,,,,,0539 OTHER OSTEOPATH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,45331,Colon (lower large bowel) examination and biopsy with endoscope [HCPCS 45331],3276.52,2457.39,2457.39,1627.56,1627.56,1627.56,,,,,,0540 AMBULANCE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],3522.49,2641.87,2641.87,0,179.75,1202.14,,,,,,0541 AMBUL/SUPPLY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],4605.38,3454.04,3454.04,2509.37,15.34,2509.37,,,,,,0542 AMBUL/MED TRANS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],4243.39,3182.54,3182.54,3309.99,246.83,3309.99,,,,,,0543 AMBUL/HEARTMOBL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,49083,Abdominal cavity fluid drainage with imaging guidance [HCPCS 49083],403,302.25,302.25,125,74.39,125,,,,,,0544 AMBUL/OXY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,49505,Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505],10239.44,7679.58,7679.58,3515.07,390,3515.07,,,,,,0545 AIR AMBULANCE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,300.7,119.94,617.26,,,,,,0546 AMBUL/NEONATAL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,51798,Measurement of bladder capacity after voiding by ultrasound [HCPCS 51798],154.4,115.8,115.8,154.4,154.4,154.4,,,,,,0547 AMBUL/PHARMACY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,70220,"Paranasal sinuses x-ray usually including 4 to 5 standard views of the skull (complete study, miniumum of 3 views) [HCPCS 70220]",225,168.75,168.75,0,94.25,94.25,,,,,,0548 AMBUL/TELEPHONIC EKG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,796.3,137.3,1347.57,,,,,,0549 OTHER AMBULANCE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,1221.85,73.48,1221.85,,,,,,0550 SKILLED NURSING,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,70551,Imaging of brain by MRI without contrast [HCPCS 70551],1046.4,784.8,784.8,533.66,218.85,533.66,,,,,,0551 SKILLED NURS/VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",1974.7,1481.03,1481.03,1005.39,561.23,1308.35,,,,,,0552 SKILLED NURS/HOUR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,250.4,20.71,250.4,,,,,,0559 SKILLED NURS/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,131.73,28.74,271.3,,,,,,0560 MED SOCIAL SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,177.23,94.25,177.23,,,,,,0561 MED SOC SERVS/VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,0,109.96,166.13,,,,,,0562 MED SOC SERV/HOUR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,387.47,137.3,1124.55,,,,,,0569 MED SOC SERV/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,0,272.21,1200.54,,,,,,0570 AIDE/HOME HEALTH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1412.4,1059.3,1059.3,0,272.21,898.39,,,,,,0571 AIDE/HOME HLTH/VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,4.45,4.45,148.78,,,,,,0572 AIDE/HOME HLTH/HOUR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,223.7,69.84,223.7,,,,,,0579 AIDE/HOME HLTH/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,4.41,4.41,166.13,,,,,,0580 VISIT/HOME HEALTH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,0,166.13,1107.72,,,,,,0581 VISIT/HOME HLTH/VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,1309.77,166.13,1309.77,,,,,,0582 VISIT/HOME HLTH/HOUR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,527.99,350.85,825.61,,,,,,0589 VISIT/HOME HLTH/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72192,"Pelvis CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 72192]",1221.6,916.2,916.2,1221.6,511.9,1221.6,,,,,,0590 UNIT/HOME HEALTH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72195,Imaging of pelvis by MRI without contrast [HCPCS 72195],1046.4,784.8,784.8,996.5,996.5,1988.16,,,,,,0599 UNIT/HOME HLTH/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,72200,X-ray of joints at hip bone and sacrum (less than 3 views) [HCPCS 72200],225,168.75,168.75,0,136.8,136.8,,,,,,0600 O2/HOME HEALTH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,222.4,94.25,222.4,,,,,,0601 O2/STAT EQUIP/SUPPL/CONT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,162.42,99,166.13,,,,,,0602 O2/STAT EQUIP/UNDER 1 LPM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,220.5,30.08,220.5,,,,,,0603 O2/STAT EQUIP/OVER 4 LPM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],1046.4,784.8,784.8,508.22,508.22,636.21,,,,,,0604 O2/STAT PORT ADD-ON,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,225,57.76,225,,,,,,0610 MRI,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],225,168.75,168.75,222.75,35.41,222.75,,,,,,0611 MRI - BRAIN,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73551,Thighbone x-ray (single view) [HCPCS 73551],225,168.75,168.75,225,94.25,225,,,,,,0612 MRI - SPINE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],225,168.75,168.75,225,94.25,225,,,,,,0614 MRI- Other,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,114.35,29.4,177.53,,,,,,0615 MRI-Head and neck,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,214.2,94.25,214.2,,,,,,0616 MRA - LOWER EXT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,73.09,73.09,246.59,,,,,,0618 MRA,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],225,168.75,168.75,225,27.06,225,,,,,,0619 OTHER MRT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,225,69.84,225,,,,,,0621 MED - SUR SUPP/INCDNT RAD,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,112.91,56.37,178.99,,,,,,0622 MED-SUR SUPP/INCDNT ODX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,0,37.7,213.75,,,,,,0623 SURG DRESSING,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73650,Foot x-ray at heel of foot (minimum of 2 views) [HCPCS 73650],225,168.75,168.75,114.55,114.55,114.55,,,,,,0624 IDE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],1046.4,784.8,784.8,0,350.85,636.21,,,,,,0630 DRUGS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,0,90,225,,,,,,0631 DRUG/SNGLE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,0,31.41,166.13,,,,,,0632 DRUG/MULT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,2535.28,180.22,3324.06,,,,,,0633 DRUG/RSTR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1240.64,561.23,2500,,,,,,"0634 DRUG/EPO<10,000 UNITS",,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",4712.1,3534.08,3534.08,2138.86,561.23,2284.78,,,,,,"0635 DRUG/EPO>10,000 UNITS",,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,0,110.94,589.78,,,,,,0636 DRUGS/DETAIL CODE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,0,62.12,274.64,,,,,,0637 DRUGS/SELF ADMIN,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,0,166.13,529.3,,,,,,0640 IV THERAPY SVC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,0,137.3,401.67,,,,,,0641 NON RT NURSING/CENTRAL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,333.49,107.93,965.26,,,,,,0642 IV SITE CARE/CENTRAL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,326.15,166.13,529.81,,,,,,0643 IV STRT/CHNG/PERIPHAL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,282.43,166.13,1065.48,,,,,,0644 NONRT NURSING/PERIPHRL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,0,23.61,157.86,,,,,,0645 TRNG PT/CARGVR/CENTRL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],485.7,364.28,364.28,462.5,84.74,462.5,,,,,,0646 TRNG DSBLPT/CENTRAL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,220.43,89.59,349.41,,,,,,0647 TRNG/PT/CARGVR/PERIPHRL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,159.39,8.49,161,,,,,,0648 TRNG/DSBLPAT/PERPHRL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,0,41.68,551.29,,,,,,0649 OTHER IV THERAPY SVC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,234.2,8.87,355.2,,,,,,0650 HOSPICE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,148.9,11.25,148.9,,,,,,0651 HOSPICE/RTN HOME,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],131.3,98.48,98.48,99.65,55,99.65,,,,,,0652 HOSPICE/CTNS HOME,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,0,48.41,364.52,,,,,,0655 HOSPICE/IP RESPITE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,183.45,8.3,183.45,,,,,,0656 HOSPICE/IP NON-RESPITE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80156,Lab analysis to measure the amount of carbamazepine (total) in blood specimen [HCPCS 80156],233.8,175.35,175.35,0,24.15,24.15,,,,,,0657 HOSPICE/PHYSICIAN,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80162,Lab analysis to measure the amount of total digoxin in blood specimen [HCPCS 80162],107,80.25,80.25,0,44.84,44.84,,,,,,0658 HOSPICE/R&B/NURS FAC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80164,Lab analysis to measure the amount of total valproic acid in blood specimen [HCPCS 80164],116.9,87.68,87.68,103.93,13.54,103.93,,,,,,0659 HOSPICE/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80177,Lab analysis to measure the amount of levetiracetam in blood specimen [HCPCS 80177],186.4,139.8,139.8,0,21.96,21.96,,,,,,0660 RESPITE CARE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],99.3,74.48,74.48,94.5,13.12,94.5,,,,,,0661 RESPITE/SKILLED NURSE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80201,Lab analysis to measure the amount of topiramate in serum or plasma specimen [HCPCS 80201],131.3,98.48,98.48,0,16.33,16.33,,,,,,0662 RESPITE/HMEAID/HMEMKR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80299,Lab analysis of therapeutic drug not elsewhere specified [HCPCS 80299],277.9,208.43,208.43,146.11,146.11,146.11,,,,,,0669 OTHER RESPITE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,291.75,14.4,297.7,,,,,,0670 OP SPEC RES,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,9.42,73.71,,,,,,0671 OP SPEC RES/HOSP BASED,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,72.5,2.66,76.2,,,,,,0672 OP SPEC RES/CONTRACTED,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,53,1.89,53,,,,,,0679 OP SPEC RES/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82010,"Lab analysis to measure the amount of ketone bodies in blood, serum, or plasma specimen [HCPCS 82010]",75.6,56.7,56.7,45.2,8.3,45.2,,,,,,0700 CAST ROOM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,0,2.31,20.91,,,,,,0709 OTHER CAST ROOM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],314.3,235.73,235.73,0,14.09,91.91,,,,,,0710 RECOVERY ROOM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],137.9,103.43,103.43,131.3,14.81,137.9,,,,,,0719 OTHER RECOV RM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,94.08,5.44,96,,,,,,0720 DELIVEROOM/LABOR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82164,Lab analysis to measure the angiotensin l - converting enzyme (ACE) level [HCPCS 82164],101.5,76.13,76.13,0,42.5,42.5,,,,,,0721 LABOR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82247,Lab analysis to measure the total bilirubin level [HCPCS 82247],118.1,88.58,88.58,50.4,4.22,50.4,,,,,,0722 DELIVERY ROOM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],30.9,23.18,23.18,0,12.94,18.79,,,,,,0723 CIRCUMCISION,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,290.1,30.08,290.1,,,,,,0724 BIRTHING CENTER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,28.7,19.16,56.63,,,,,,0729 OTHER/DELIV-LABOR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,62,5.81,65.1,,,,,,0730 EKG/ECG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,98.31,11.55,98.31,,,,,,0731 HOLTER MONT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,81.23,4.35,81.23,,,,,,0732 TELEMETRY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,0,12.67,98.39,,,,,,0739 OTHER EKG-ECG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,461.58,32.34,465.3,,,,,,0740 EEG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,112.4,11.45,112.4,,,,,,0749 OTHER EEG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,0,14.94,192.28,,,,,,0750 GASTR-INTS SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82803,Lab analysis to measure the amount of blood gases [HCPCS 82803],293.3,219.98,219.98,223.7,26.5,223.7,,,,,,0759 OTHER GASTRO-INTS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,8.7,2.66,8.7,,,,,,0760 TREATMENT/OBSERVATION RM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,66.45,8.16,104.31,,,,,,0761 TREATMENT RM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,453.2,11.58,453.2,,,,,,0762 OBSERVATION RM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,0,5.43,33.59,,,,,,0769 OTHER TREATMENT RM,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,0,7.34,38.68,,,,,,0770 PREVENT CARE SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,190.22,9.72,190.22,,,,,,0771 VACCINE ADMIN,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,30.9,5.07,94.54,,,,,,0779 OTHER PREVENT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83655,Lab analysis to measure the lead level in blood specimen [HCPCS 83655],123.5,92.63,92.63,122.26,12.31,122.26,,,,,,0780 TELEMEDICINE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,103.78,5,105.9,,,,,,0789 TELEMEDICINE/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,72.8,5.63,72.8,,,,,,0790 LITHOTRIPSY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,268.8,32.98,268.8,,,,,,0799 LITHOTRIPSY/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,133.85,41.96,133.85,,,,,,0800 RENAL DIALYSIS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,40.9,4.75,40.9,,,,,,0801 DIALY/INPT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,315.4,18.45,315.4,,,,,,0802 DIALY/INPT/PER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,0,3.73,46.16,,,,,,0803 DIALY/INPT/CAPD,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84166,Lab analysis to measure the amount of protein in body fluid specimen [HCPCS 84166],233.8,175.35,175.35,229.12,17.83,229.12,,,,,,0804 DIALY/INPT/CCPD,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,228.9,25.9,240.4,,,,,,0809 DIALY/INPT/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],61.8,46.35,46.35,0,11.39,37.57,,,,,,0810 ORGAN ACQUISIT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,130.1,7.58,134.6,,,,,,0811 LIVING DONOR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,134.34,14.11,134.34,,,,,,0812 CADAVER DONOR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84479,Lab analysis to evaluate thyroid hormone in serum specimen [HCPCS 84479],61.8,46.35,46.35,7.26,7.26,25.87,,,,,,0813 UNKNOWN DONOR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,153.94,14.41,153.94,,,,,,0814 UNSUCCESSFUL SEARCH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",233.8,175.35,175.35,200.91,17.22,200.91,,,,,,0815 HEART/CADAVER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,134.4,9.87,141.2,,,,,,0816 HEART/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,0,4.54,50.4,,,,,,0817 LIVER ACQUISIT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,191.3,17.05,191.3,,,,,,0819 ORGAN DONOR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],44.1,33.08,33.08,10,2.41,10,,,,,,0820 HEMO/OP OR HOME,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],12.2,9.15,9.15,10,2.41,10,,,,,,0821 HEMO/OP/COMPOSITE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,84,6,88.2,,,,,,0822 HEMO/HOME/SUPPL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,29.84,5.43,37.5,,,,,,0823 HEMO/HOME/EQUIP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,182.7,8.55,182.7,,,,,,0824 HEMO/HOME/100%,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85549,Lab analysis to measure white blood cell enzyme activity [HCPCS 85549],155.5,116.63,116.63,141.79,141.79,141.79,,,,,,0825 HEMO/HOME/SUPSERV,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,68.9,3.6,69.6,,,,,,0829 HEMO/HOME/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,0,3.56,42,,,,,,0830 PERITONEAL/OP OR HOME,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,0,2.7,54.33,,,,,,0831 PERTNL/COMPOSITE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,66.2,6.03,69.6,,,,,,0832 PERTNL/HOME/SUPPL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,258.33,12.29,258.33,,,,,,0833 PERTNL/HOME/EQUIP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86039,Lab analysis to screen for autoimmune disorders by titer [HCPCS 86039],91.6,68.7,68.7,0,18.5,73.28,,,,,,0834 PERTNL/HOME/100%,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,0,5.26,76.2,,,,,,0835 PERTNL/HOME/SUPSERV,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86147,Lab analysis to identify tissue antibody cardiolipin [HCPCS 86147],116.9,87.68,87.68,105.69,105.69,105.69,,,,,,0839 PERTNL/HOME/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,0,12.2,112.96,,,,,,0840 CAPD/OP OR HOME,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86225,Lab analysis to identify antibodies to native or double stranded DNA [HCPCS 86225],141.2,105.9,105.9,68.99,62.13,112.96,,,,,,0841 CAPD/COMPOSITE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,148.1,18.22,199.4,,,,,,0842 CAPD/HOME/SUPPL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,167.19,12.25,187.04,,,,,,0843 CAPD/HOME/EQUIP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86320,Lab analysis by immunologic analysis technique on serum [HCPCS 86320],164.4,123.3,123.3,33.79,33.79,33.79,,,,,,0844 CAPD/HOME/100%,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,121.3,14.79,121.3,,,,,,0845 CAPD/HOME/SUPSERV,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,186.4,5.76,186.4,,,,,,0849 CAPD/HOME/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,0,4.34,61.8,,,,,,0850 CCPD/OP OR HOME,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86628,Lab analysis to identify antibodies to Candida (yeast) [HCPCS 86628],71.8,53.85,53.85,67.15,67.15,67.15,,,,,,0851 CCPD/COMPOSITE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86682,Lab analysis to identify antibodies to helminth (intestinal worm) [HCPCS 86682],92.9,69.68,69.68,45.08,45.08,45.08,,,,,,0852 CCPD/HOME/SUPPL,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86695,"Lab analysis to identify antibodies to Herpes simplex virus, type 1 [HCPCS 86695]",194.1,145.58,145.58,27.06,13.41,58.37,,,,,,0853 CCPD/HOME/EQUIP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86696,"Lab analysis to identify antibodies to Herpes simplex virus, type 2 [HCPCS 86696]",413.5,310.13,310.13,254.75,19.67,254.75,,,,,,0854 CCPD/HOME/100%,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,0,11.52,121.3,,,,,,0855 CCPD/HOME/SUPSERV,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86704,Lab analysis to identify Hepatitis B core antibodies (IgG and IgM) [HCPCS 86704],155.5,116.63,116.63,153.94,65.16,153.94,,,,,,0859 CCPD/HOME/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86705,Lab analysis to identify Hepatitis B core antibodies (IgM) [HCPCS 86705],130.1,97.58,97.58,0,54.52,54.52,,,,,,0880 DIALY/MISC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86706,Lab analysis to identify Hepatitis B surface antibodies [HCPCS 86706],113.7,85.28,85.28,0,42.06,47.61,,,,,,0881 DIALY/ULTRAFILT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,81.35,11.99,222.7,,,,,,0882 HOME DIALYSIS AID VISIT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,77.62,6.74,92.02,,,,,,0889 DIALY/MISC/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,61.18,2.99,62.24,,,,,,0900 PSYCH TREATMENT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,48.11,2.99,48.11,,,,,,0901 ELECTRO SHOCK,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,122.26,11.93,144.95,,,,,,0902 MILIEU THERAPY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,0,9.2,112.32,,,,,,0903 PLAY THERAPY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,8.53,7.24,496.86,,,,,,0904 ACTIVITY THERAPY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,0,9.38,86.39,,,,,,0905 BH/INTENS OP/PSYCH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,99.4,6.79,100.4,,,,,,0906 BH/INTENS OP/CHEM DEP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,108.1,2.84,108.1,,,,,,0907 BH/COMMUNITY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,24.3,6.8,52.43,,,,,,0909 OTHER PSYCH RX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,168.56,7.27,172,,,,,,0910 PSYCH SERVICES,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,0,4.29,39.3,,,,,,0911 PSYCH/REHAB,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87254,Lab analysis of isolated viruses by centrifuge enhanced method [HCPCS 87254],419,314.25,314.25,0,19.88,254.75,,,,,,0912 PSYCH/PARTIAL HOSP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87255,Lab analysis of isolated viruses by non-immunologic method [HCPCS 87255],326.4,244.8,244.8,0,56.12,198.45,,,,,,0913 PSYCH/PARTIAL INTENSIVE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87339,Lab analysis by immunoassay (ELISA) to identify helicobacter pylori (GI tract bacteria) [HCPCS 87339],217.3,162.98,162.98,16,13,16,,,,,,0914 PSYCH/INDIV RX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87340,Lab analysis by immunoassay (ELISA) to identify Hepatitis B surface antigen [HCPCS 87340],105.9,79.43,79.43,0,10.5,44.35,,,,,,0915 PSYCH/GROUP RX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,155.5,8.17,155.5,,,,,,0916 PSYCH/FAMILY RX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,45.23,37.79,110.3,,,,,,0917 PSYCH/BIOFEED,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,0,29.48,155.5,,,,,,0918 PSYCH/TESTING,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87522,Lab analysis to measure the amount of Hepatitis C virus [HCPCS 87522],325.3,243.98,243.98,322.55,143.13,322.55,,,,,,0919 PSYCH/OTHER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,0,29.48,155.5,,,,,,0920 OTHER DX SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,0,4.29,35.67,,,,,,0921 PERI VASCUL LAB,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,157.5,45.82,378.9,,,,,,0922 EMG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,0,29.48,105,,,,,,0923 PAP SMEAR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,398.76,40.24,406.9,,,,,,0924 ALLERGY TEST,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,0,4.29,27.04,,,,,,0925 PREG TEST,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,0,13.86,24.19,,,,,,0929 ADDITIONAL DX SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,0,20.12,77.89,,,,,,0931 HALF DAY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,62.48,6.15,4344.87,,,,,,0932 FULL DAY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",1427.8,1070.85,1070.85,714.62,350.85,944.09,,,,,,0940 OTHER RX SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,360.44,166.13,1092.27,,,,,,0941 RECREATION RX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,0,16.49,98.36,,,,,,0942 EDUC/TRAINING,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,0,19.15,448.97,,,,,,0943 CARDIAC REHAB,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,425.3,28.6,1161.38,,,,,,0944 DRUG REHAB,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,75.66,16.26,2475.42,,,,,,0945 ALCOHOL REHAB,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,425.3,68.61,524.17,,,,,,0946 RTN CMPLX MED EQUIP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,73.5,20.72,3197.1,,,,,,0947 CMPLX MED EQUIP,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,143.78,34.19,143.78,,,,,,0949 ADDITIONAL RX SVS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,156.9,4.51,1156.79,,,,,,0951 ATHLETIC TRAINING,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,199.6,29.4,2785.69,,,,,,0952 KINESIOTHERAPY,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,37.8,12.56,48.28,,,,,,0960 PRO FEE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,10.24,10.24,44.01,,,,,,0961 PRO FEE/PSYCH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,56.89,40.84,136.8,,,,,,0962 PRO FEE/EYE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,62.48,40.84,143.78,,,,,,0963 PRO FEE/ANES MD,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],101.5,76.13,76.13,51.77,37.78,80.08,,,,,,0964 PRO FEE/ANES CRNA,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,42.4,23.51,98.36,,,,,,0969 OTHER PRO FEE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,177.28,140.59,428.4,,,,,,0971 PRO FEE/LAB,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,184.54,140.59,241.75,,,,,,0972 PRO FEE/RAD/DX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,66.96,40.84,154.11,,,,,,0973 PRO FEE/RAD/RX,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,97761,"Prosthesis use training for arms and/or legs (initial encounter, each 15 minutes) [HCPCS 97761]",131.3,98.48,98.48,63.75,63.75,63.75,,,,,,0974 PRO FEE/NUC MED,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,0,10.32,28.14,,,,,,0975 PRO FEE/OR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,265.5,35.11,337.46,,,,,,0976 PRO FEE/RESPIR,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,265.5,70.45,319.43,,,,,,0977 PRO FEE/PHYSI,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,74.99,2.2,117.5,,,,,,0978 PRO FEE/OCCUPA,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,233.22,39.1,434.06,,,,,,0979 PRO FEE/SPEECH,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,366.5,61.48,2109.82,,,,,,0981 PRO FEE/ER,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,570.1,50,3116.59,,,,,,0982 PRO FEE/OUTPT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,891.5,62.92,1098.7,,,,,,0983 PRO FEE/CLINIC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],2468.09,1851.07,1851.07,754.54,754.54,754.54,,,,,,0984 PRO FEE/SOC SVC,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,2.42,2.42,250.2,,,,,,0985 PRO FEE/EKG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,G0328,Fecal blood scrn immunoassay [HCPCS G0328],48.8,36.6,36.6,48.31,20.42,48.31,,,,,,0986 PRO FEE/EEG,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,0,5.83,3301.98,,,,,,0987 PRO FEE/HOS VIS,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,0,7.4,19.63,,,,,,0988 PRO FEE/CONSULT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,461.27,167.53,728.8,,,,,,0989 FEE/PVT NURSE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Institutional,Outpatient,U0004,"2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r [HCPCS U0004]",89.3,66.98,66.98,43.47,39.29,43.47,,,,,,0990 PT CONVENIENCE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,68.56,52.38,170.1,,,,,,0991 CAFETERIA,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,129.79,81.71,178.67,,,,,,0992 LINEN,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.25,22.37,41.75,,,,,,0993 TELEPHONE,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,0994 TV/RADIO,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,69.53,45.48,91.29,,,,,,0995 NONPT ROOM RENT,,,,,,
HUMANA INC. - Medicare-HMO,Hospital,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.58,59.99,274.04,,,,,,0996 LATE DISCHARGE,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,69.82,69.82,69.82,,,,,,0997 ADMIT KITS,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],49.7,37.28,37.28,94.91,69.32,94.91,,,,,,0998 BARBER/BEAUTY,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],310.8,233.1,233.1,131.34,130.46,326.4,,,,,,0999 PT CONVENCE/OTH,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],189.7,142.28,142.28,69.53,69.53,69.53,,,,,,1000 BH R&B,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],162.8,122.1,122.1,69.53,64.49,171,,,,,,1001 BH R&B RES/PSYCH,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,300,Anesthesia provided during esophagus and neck procedure [HCPCS 00300],139,104.25,104.25,46.89,6.45,46.89,,,,,,1002 BH R&B RES/CHEM DEP,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,28.42,1.64,80.91,,,,,,1003 BH R&B SUP LIVING,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,31.26,1.93,464.4,,,,,,1004 BH R&B HALFWAY HOUSE,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,830,Anesthesia provided during lower abdominal hernia repair [HCPCS 00830],139,104.25,104.25,28.42,1.95,28.42,,,,,,1005 BH R&B GROUP HOME,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,1810,"Anesthesia provided during procedure on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand [HCPCS 01810]",139,104.25,104.25,33.34,33.34,33.34,,,,,,2100 ALTTHERAPY,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,21012,Tissue tumor removal beneath the skin of face and scalp (2 cm or greater) [HCPCS 21012],858.3,643.73,643.73,328.18,328.18,328.18,,,,,,2101 ACUPUNCTURE,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,26160,Tendon lesion removal from finger or hand [HCPCS 26160],986.8,740.1,740.1,301.92,301.92,301.92,,,,,,2102 ACCUPRESSURE,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,45331,Colon (lower large bowel) examination and biopsy with endoscope [HCPCS 45331],912.9,684.68,684.68,67.92,67.92,67.92,,,,,,2103 MASSAGE,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,51.74,51.74,302.2,,,,,,2104 REFLEXOLOGY,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,192.01,192.01,343.2,,,,,,2105 BIOFEEDBACK,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,246.4,168.37,416.16,,,,,,2106 HYPNOSIS,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,49507,Groin hernia repair for patient 5 years of age or older (herniated tissue that is trapped) [HCPCS 49507],2617.4,1963.05,1963.05,566.52,566.52,947.94,,,,,,2109 OTHER ALTTHERAPY,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,343.3,214.38,2255.8,,,,,,3101 ADULT MED/SOC HR,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,68.56,52.38,170.1,,,,,,3102 ADULT SOC HR,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,93.27,52.53,206.9,,,,,,3103 ADULT MED/SOC DAY,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,129.79,81.71,178.67,,,,,,3104 ADULT SOC DAY,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,97.06,59.92,194.57,,,,,,3105 ADULT FOSTER DAY,,,,,,
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,131.34,95.05,222.03,,,,,,XR Finger(1st Digit) 2+ Views Left,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,191.66,120.14,248.05,,,,,,XR Finger(1st Digit) 2+ Views Right,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.25,22.37,41.75,,,,,,XR Finger(2nd Digit) 2+ Views Left,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,69.53,39.55,134.08,,,,,,XR Finger(2nd Digit) 2+ Views Right,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,XR Finger(3rd Digit) 2+ Views Left,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,69.53,45.48,91.29,,,,,,XR Finger(3rd Digit) 2+ Views Right,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,126.93,114.76,176.55,,,,,,XR Finger(4th Digit) 2+ Views Left,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99235,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235],458.7,344.03,344.03,159.94,142.98,177.83,,,,,,XR Finger(4th Digit) 2+ Views Right,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99236,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of high severity (55 minutes per day) [HCPCS 99236],568.9,426.68,426.68,200.72,191.28,228.53,,,,,,XR Finger(5th Digit) 2+ Views Left,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.58,59.99,274.04,,,,,,XR Finger(5th Digit) 2+ Views Right,73140,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],415.7,311.78,311.78,86.79,86.79,92.46,,,,,,XR Toe(1st Digit) 2+ Views Left,73660,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,42.53,41.76,46.23,,,,,,XR Toe(1st Digit) 2+ Views Right,73660,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,66.64,66.42,66.64,,,,,,XR Toe(2nd Digit) 2+ Views Left,73660,0320,,225,168.75,168.75
HUMANA INC. - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",333,249.75,249.75,70.49,69.22,77.17,,,,,,XR Toe(2nd Digit) 2+ Views Right,73660,0320,,225,168.75,168.75
HUMANA INSURANCE - Commercial-HMO,Hospital,Institutional,Inpatient,74,Cranial & peripheral nerve disorders without major complications,21172.68,15879.51,15879.51,69.6,69.6,3586.14,,,,,,XR Toe(3rd Digit) 2+ Views Left,73660,0320,,225,168.75,168.75
ALLEGIANCE BENEFIT PLAN MANAGEMENT - Commercial-PPO,,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,18.97,15.77,25,,,,,,XR Toe(3rd Digit) 2+ Views Right,73660,0320,,225,168.75,168.75
ALLEGIANCE BENEFIT PLAN MANAGEMENT - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,73.59,62.38,245.75,,,,,,XR Toe(4th Digit) 2+ Views Left,73660,0320,,225,168.75,168.75
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,0,5.03,33.1,,,,,,XR Toe(4th Digit) 2+ Views Right,73660,0320,,225,168.75,168.75
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,XR Toe(5th Digit) 2+ Views Left,73660,0320,,225,168.75,168.75
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,0,18.04,43.1,,,,,,XR Toe(5th Digit) 2+ Views Right,73660,0320,,225,168.75,168.75
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,0,18.04,43.1,,,,,,96376 IV ADDITIONAL PUSH SAME DRUG CHARGE,96376,0260,,37.5,28.125,28.125
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,0,4.42,42.84,,,,,,00160 PROC NOSE/ACCESSORY SINUS ProFee,00160,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,20.81,5.2,40.9,,,,,,00402 BREAST AUGMEN/REDUCTION ProFee,00402,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,0,3.99,48.28,,,,,,00450 PROC CLAVICLE AND SCAPULA ProFee,00450,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,0,5.07,94.54,,,,,,00532 ACCESS CENTRAL VENOUS CIR ProFee,00532,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,0,13.86,33.1,,,,,,00832 VENTRAL INCISIONAL HERNIA ProFee,00832,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,0,4.75,40.9,,,,,,00846 HYSTERECTOMY ProFee,00846,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,0,7.89,28.7,,,,,,00860 EXTRAPERITONEAL LOWER ABD ProFee,00860,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,00862 RENAL PROC1/3URETER/DONOR ProFee,00862,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,0,18.48,44.1,,,,,,00910 TRANSURETHRAL PROC URETHR ProFee,00910,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,0,4.35,39.58,,,,,,00914 TRANSURETH RESECT PROSTAT ProFee,00914,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,0,5.83,44.1,,,,,,00918 PERINEAL PROC W/ FRAG MAN ProFee,00918,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,22.18,4.02,32.1,,,,,,00926 RADICAL ORCHIECTOMY INGUI ProFee,00926,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,254.69,105.86,1389.2,,,,,,00930 ORCHIOPEXY UNI OR BILATER ProFee,00930,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,246.74,70.45,319.43,,,,,,00940 VAG PROCEDURES INCL BIOPS ProFee,00940,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,307.62,107.28,315.01,,,,,,00944 VAGINAL HYSTERECTOMY ProFee,00944,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,0,6.13,13.93,,,,,,01112 BONE MARROW ASPIRATION BX ProFee,01112,,,,,
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0,0.63,1.44,,,,,,01200 CLOSED PROC HIP JOINT ProFee,01200,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.4,2.44,580.94,,,,,,01220 ANES CLSD UPPER 2/3 FEMUR ProFee,01220,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,49321,Abdominal examination and biopsy with endoscope [HCPCS 49321],7025.62,5269.22,5269.22,1932.48,1932.48,1932.48,,,,,,"01250 NERVES,MUSC,TENDON,FASCIA ProFee",01250,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,135.89,20.71,250.4,,,,,,01260 VEIN UPPER LEG INC EXPLOR ProFee,01260,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,113.65,28.74,271.3,,,,,,01340 ANES OPN PROC LWER 1/3FEM ProFee,01340,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,94.25,30.08,220.5,,,,,,01360 OPEN PROC LOWER 1/3 FEMUR ProFee,01360,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,122.09,90,225,,,,,,01380 CLSD KNEE ARTHROSCOPY ProFee,01380,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1052,561.23,2500,,,,,,01462 CLSD PROC ANKLE LOWER LEG ProFee,01462,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,371,166.13,529.3,,,,,,01470 PROC NER MUS TEN LOW LEG ProFee,01470,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],309.9,232.43,232.43,22.66,22.66,204.92,,,,,,01610 PROC NERVE MUSC SHLDR AXI ProFee,01610,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,87.38,8.49,161,,,,,,01620 CLSD PROC SHOULDER JOINT ProFee,01620,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,133.49,8.87,355.2,,,,,,01730 CLSD PROC HUMERUS ELBOW ProFee,01730,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,62.39,11.25,148.9,,,,,,01770 ANES PROC ART UP/ARM ELBO ProFee,01770,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,41.33,2.66,76.2,,,,,,01780 VEINS UPPER ARM AND ELBOW ProFee,01780,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,11.09,2.31,20.91,,,,,,"01820 CLSD PROC WRIST,HAND ProFee",01820,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,20.81,5.2,40.9,,,,,,"01840 PROC ARTER FOREARM,WRIST ProFee",01840,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,40.66,4.35,81.23,,,,,,01844 VASCULAR SHUNT REVISION ProFee,01844,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,194.96,32.34,465.3,,,,,,01960 VAGINAL DELIVERY ProFee,01960,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,48.53,8.16,104.31,,,,,,01961 CESAREAN DELIVERY ProFee,01961,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,105.34,9.72,190.22,,,,,,01962 ANES FOR URNT HYSTO F/DEL ProFee,01962,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,57.46,5,105.9,,,,,,01965 INCOMPLETE/MISSED ABORTIO ProFee,01965,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,118.27,32.98,268.8,,,,,,01967 LABOR ANALGESIA/VAG DELIV ProFee,01967,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,54.52,7.58,134.6,,,,,,01968 CES DEL AFTR LABR ANALGESIA ProFee,01968,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,56.85,14.11,134.34,,,,,,01969 CES HYST AFTR LABR ANL/AN ProFee,01969,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,22.18,4.02,32.1,,,,,,01991 ANES NERVE BLOCK/INJ ProFee,01991,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,81.8,17.05,191.3,,,,,,01992 PRONE POSITION ProFee,01992,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,47.88,6,88.2,,,,,,01996 DAILY HOSP MGMNT EPIDURL ProFee,01996,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,58.65,2.84,108.1,,,,,,10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE ProFee,10021,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,13.45,6.8,52.43,,,,,,"10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS O ProFee",10060,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,89.78,45.82,378.9,,,,,,"10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS O ProFee",10061,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,88108,Lab examination of specimen by the conentration technique to diagnose disease [HCPCS 88108],33.1,24.83,24.83,13.86,13.86,38.85,,,,,,10081 INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED ProFee,10081,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,13.86,13.86,24.19,,,,,,"10120 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE ProFee",10120,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,66.46,6.15,4344.87,,,,,,"11004 DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSU ProFee",11004,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,41.9,16.26,2475.42,,,,,,"11104 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), ProFee",,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,89.43,4.51,1156.79,,,,,,"11200 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 L ProFee",11200,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,171.8,29.4,2785.69,,,,,,"11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAM ProFee",11300,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,16.63,12.56,48.28,,,,,,"11311 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, ProFee",11311,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,16.63,10.24,44.01,,,,,,"11313 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, ProFee",11313,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,161.26,61.48,2109.82,,,,,,"11400 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11400,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,309.45,50,3116.59,,,,,,"11401 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11401,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,508.16,62.92,1098.7,,,,,,"11402 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11402,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,13.17,5.83,3301.98,,,,,,"11403 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11403,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,5.5,5.5,14.67,,,,,,"11404 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11404,0521,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,3.56,0.68,2868.2,,,,,,"11406 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11406,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,5.5,5.5,14.67,,,,,,"11421 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11421,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,14.25,3.15,30.39,,,,,,"11422 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11422,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.13,0.95,3583.7,,,,,,"11423 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11423,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,14.25,2.81,811.33,,,,,,"11424 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11424,0521,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.55,0.55,29.34,,,,,,"11426 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11426,,,,,
"HUMANA, INC. - Medicare Part B",Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,351.42,214.38,2255.8,,,,,,"11441 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11441,,,,,
"HUMANA, INC. - Medicare Part B",Dialysis Clinic,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,290.97,242.91,1540,,,,,,"11442 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11442,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,40.16,1.64,80.91,,,,,,"11443 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11443,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,42.54,4.8,352,,,,,,"11444 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11444,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,195.09,192.01,343.2,,,,,,"11446 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11446,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,49321,Abdominal examination and biopsy with endoscope [HCPCS 49321],1242.6,931.95,931.95,332.83,332.83,332.83,,,,,,"11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR IN ProFee",11450,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,69.82,52.38,170.1,,,,,,"11601 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0 ProFee",11601,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,94.91,52.53,206.9,,,,,,"11606 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER O ProFee",11606,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,94.93,59.92,194.57,,,,,,"11621 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11621,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,67.86,45.48,91.29,,,,,,"11622 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11622,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,126.93,114.76,176.55,,,,,,"11623 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11623,,,,,
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,68.47,59.99,274.04,,,,,,"11624 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11624,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,289.76,35.11,337.46,,,,,,"11626 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11626,0960,,"1,556.8",1167.6,1167.6
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,"11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE ProFee",11730,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,315.01,107.28,315.01,,,,,,11770 EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE ProFee,11770,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.73,2.44,580.94,,,,,,11771 EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE ProFee,11771,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,140.88,20.71,250.4,,,,,,11772 EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED ProFee,11772,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,128.25,69.84,225,,,,,,11971 REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS ProFee,11971,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,128.25,56.37,178.99,,,,,,"11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT ProFee",11981,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,137.42,8.87,355.2,,,,,,"12001 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK ProFee",12001,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,42.56,2.66,76.2,,,,,,"12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS M ProFee",12011,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,59.15,5,105.9,,,,,,"12032 REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HA ProFee",12032,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,78.87,9.87,141.2,,,,,,"12053 REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANE ProFee",12053,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.26,6,88.2,,,,,,"13121 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM ProFee",13121,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,86.87,8.17,155.5,,,,,,"15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ CM OR ProFee",15200,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,92.39,45.82,378.9,,,,,,"15240 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, ProFee",15240,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,58.65,29.48,105,,,,,,"15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA ProFee",15839,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,68.92,6.15,4344.87,,,,,,"17106 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS TH ProFee",17106,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,219.39,61.48,2109.82,,,,,,"17110 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CU ProFee",17110,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,320.74,50,3116.59,,,,,,"19101 BIOPSY OF BREAST; OPEN, INCISIONAL ProFee",19101,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,0,1.28,46.3,,,,,,"19120 EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TI ProFee",19120,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,0,15.77,25,,,,,,"19301 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); ProFee",19301,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,0,45.56,141.93,,,,,,"19302 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH A ProFee",19302,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,72.8,13.55,72.8,,,,,,20103 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY ProFee,20103,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,100.8,62.38,245.75,,,,,,"20610 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, ProFee",20610,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,0,70,166.6,,,,,,"21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX ProFee",21550,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,0,52.38,170.1,,,,,,"21556 EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR ProFee",21556,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-Indemnity,,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,0,52.53,206.9,,,,,,"22903 EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER ProFee",22903,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,11.3,2.07,19.9,,,,,,"23075 EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM ProFee",23075,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,82,12.82,82,,,,,,"23655 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA ProFee",23655,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,37.66,1.28,46.3,,,,,,"24071 EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER ProFee",24071,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,20.5,15.77,25,,,,,,"26160 EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLI ProFee",26160,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,"27045 EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 ProFee",,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,106.1,45.56,141.93,,,,,,"27047 EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; LESS THAN 3 CM ProFee",27047,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,202.54,140.39,202.54,,,,,,"27337 EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER ProFee",27337,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,65.84,13.55,72.8,,,,,,"27603 INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA ProFee",27603,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,100,62.38,245.75,,,,,,"28150 PHALANGECTOMY, TOE, EACH TOE ProFee",28150,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,150.67,70,166.6,,,,,,"28232 TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE) ProFee",28232,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,65.1,65.1,68.4,,,,,,"28312 OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; OTHER PHALANGES, ANY TOE ProFee",28312,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,372.57,14.35,372.57,,,,,,"28810 AMPUTATION, METATARSAL, WITH TOE, SINGLE ProFee",28810,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,19.42,1.39,26.3,,,,,,"28820 AMPUTATION, TOE; METATARSOPHALANGEAL JOINT ProFee",28820,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,5.2,0.08,6.58,,,,,,31575 LARYNGOSCOPY FLEXIBLE DIAGNOSTIC ProFee,31575,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,26.3,5.44,26.3,,,,,,"31600 TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); ProFee",31600,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],26.3,19.73,19.73,19.43,5.39,19.43,,,,,,"31603 TRACHEOSTOMY, EMERGENCY PROCEDURE; TRANSTRACHEAL ProFee",31603,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.65,1.1,17.76,,,,,,"32551 TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFO ProFee",32551,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,Hospital,Institutional,Outpatient,72195,Imaging of pelvis by MRI without contrast [HCPCS 72195],1046.4,784.8,784.8,1988.16,996.5,1988.16,,,,,,32552 REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF ProFee,32552,,,,,
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,2358.98,180.22,3324.06,,,,,,36510 NEWBORN UMBILICAL VEIN CATH CHARGE,36510,0360,,142.3,106.725,106.725
INSURANCE MANAGEMENT SERVICES - Commercial-PPO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,2500,561.23,2500,,,,,,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR O ProFee,36556,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,0,5.03,33.1,,,,,,"36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS ProFee",36558,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,"36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEO ProFee",36561,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,0,18.04,43.1,,,,,,"36569 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOU ProFee",36569,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,0,18.04,43.1,,,,,,"36575 REPAIR OF TUNNELED OR NON-TUNNELED CENTRAL VENOUS ACCESS CATHETER, WITHOUT SUBCUTANEOU ProFee",36575,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,0,4.42,42.84,,,,,,"36589 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP ProFee",36589,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,0,5.2,40.9,,,,,,"36590 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENT ProFee",36590,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,0,3.99,48.28,,,,,,"36600 ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS ProFee",36600,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,0,5.07,94.54,,,,,,"36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPAR ProFee",36620,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,0,13.86,33.1,,,,,,36660 NEWBORN UMBILICAL ARTERY CATH CHARGE,36660,0360,,158.8,119.1,119.1
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,0,4.75,40.9,,,,,,"37609 LIGATION OR BIOPSY, TEMPORAL ARTERY ProFee",37609,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,0,7.89,28.7,,,,,,"38500 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL ProFee",38500,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,38700 SUPRAHYOID LYMPHADENECTOMY ProFee,38700,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,0,18.48,44.1,,,,,,"40812 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR ProFee",40812,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,0,4.35,39.58,,,,,,"43235 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF S ProFee",43235,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,0,5.83,44.1,,,,,,"43239 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE ProFee",43239,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,0,4.02,32.1,,,,,,"43246 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEO ProFee",43246,,,,,
INTERMOUNTAIN HEALTHCARE NEVADA - Commercial-Indemnity,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,195.18,105.86,1389.2,,,,,,"43247 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S) ProFee",43247,,,,,
INTERNATIONAL BENEFITS ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,0,15.77,25,,,,,,"43250 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), O ProFee",43250,,,,,
INTERNATIONAL BENEFITS ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,106.1,45.56,141.93,,,,,,"43251 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), O ProFee",43251,,,,,
INTERNATIONAL BENEFITS ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,50,13.55,72.8,,,,,,"43760 CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE ProFee",,,,,,
INTERNATIONAL BENEFITS ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,"43870 CLOSURE OF GASTROSTOMY, SURGICAL ProFee",43870,,,,,
INTERNATIONAL BENEFITS ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,0,70,166.6,,,,,,44005 ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE) ProFee,44005,,,,,
INTERNATIONAL BENEFITS ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,0,147.2,226.48,,,,,,"44120 ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND ANASTOMOSIS ProFee",44120,,,,,
KAISER - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,"44143 COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PR ProFee",44143,,,,,
KAISER - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,74.32,51.31,199.63,,,,,,"44145 COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) ProFee",44145,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.85,2.44,580.94,,,,,,"44180 LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDUR ProFee",44180,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,370.3,137.3,529.3,,,,,,"44204 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS ProFee",44204,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,"44205 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH ILEOCOL ProFee",44205,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,29.91,1.89,53,,,,,,"44208 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW ProFee",44208,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,"44310 ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE ProFee",44310,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,62.24,2.99,62.24,,,,,,44320 COLOSTOMY OR SKIN LEVEL CECOSTOMY; ProFee,44320,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,252.91,28.6,1161.38,,,,,,"44376 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING I ProFee",44376,,,,,
KENTUCKY MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,322.85,50,3116.59,,,,,,"44392 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY H ProFee",44392,,,,,
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,44.01,13.55,72.8,,,,,,"44603 SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, I ProFee",44603,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,289.76,35.11,337.46,,,,,,"44626 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND COLORECTAL ANASTO ProFee",44626,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,319.43,70.45,319.43,,,,,,44640 CLOSURE OF INTESTINAL CUTANEOUS FISTULA ProFee,44640,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,316.64,236.82,316.64,,,,,,44950 APPENDECTOMY; ProFee,44950,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.85,2.44,580.94,,,,,,44955 APPENDECTOMY; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (NOT AS ProFee,44955,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,853.46,137.3,1347.57,,,,,,"44970 LAPAROSCOPY, SURGICAL, APPENDECTOMY ProFee",44970,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,141.8,20.71,250.4,,,,,,"45300 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY B ProFee",45300,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,113.65,28.74,271.3,,,,,,"45330 SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING O ProFee",45330,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,"45331 SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE ProFee",45331,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,124.74,14.4,297.7,,,,,,45355 COLSC RGD/FLX TABDL VIA COLOTOMY 1/MLT ProFee,,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,36.04,9.42,73.71,,,,,,"45378 COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR ProFee",45378,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,31.9,2.66,76.2,,,,,,45383 COLONOSCOPY W CAUTERIZATION ProFee,,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,28.73,1.89,53,,,,,,"45385 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE ProFee",45385,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,54.17,5.44,96,,,,,,"45398 COLONOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS) ProFee",45398,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.24,2.66,8.7,,,,,,45915 REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA ProFee,45915,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,59.76,5,105.9,,,,,,46020 PLACEMENT OF SETON ProFee,46020,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,56.85,14.11,134.34,,,,,,46040 INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE) ProFee,46040,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,76.61,9.87,141.2,,,,,,"46050 INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL ProFee",46050,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,"46083 INCISION OF THROMBOSED HEMORRHOID, EXTERNAL ProFee",46083,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,29.13,3.6,69.6,,,,,,"46221 HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S) ProFee",46221,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,76.61,9.2,112.32,,,,,,"46230 EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS ProFee",46230,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.06,6.79,100.4,,,,,,"46255 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; ProFee",46255,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.07,7.27,172,,,,,,"46260 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; ProFee",46260,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,87.75,8.17,155.5,,,,,,46270 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS ProFee,46270,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,93.34,45.82,378.9,,,,,,46275 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC ProFee,46275,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,66.46,6.15,4344.87,,,,,,"46600 ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN ProFee",46600,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,44,16.26,2475.42,,,,,,"46924 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPE ProFee",46924,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,148.76,68.61,524.17,,,,,,"46940 CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF ANAL SPHINCTER (SEPARATE P ProFee",46940,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,32.34,20.72,3197.1,,,,,,"46946 HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID C ProFee",46946,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,38.81,34.19,143.78,,,,,,"47100 BIOPSY OF LIVER, WEDGE ProFee",47100,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,93.94,4.51,1156.79,,,,,,"47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY ProFee",47562,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,179.24,29.4,2785.69,,,,,,"47563 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY ProFee",47563,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,21.38,12.56,48.28,,,,,,47600 CHOLECYSTECTOMY; ProFee,47600,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,21.38,10.24,44.01,,,,,,47605 CHOLECYSTECTOMY; WITH CHOLANGIOGRAPHY ProFee,47605,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,161.26,61.48,2109.82,,,,,,47610 CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; ProFee,47610,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,530.12,62.92,1098.7,,,,,,47801 PLACEMENT OF CHOLEDOCHAL STENT ProFee,47801,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,16.45,5.83,3301.98,,,,,,"49000 EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR WITHOUT BIOPSY(S) (SEPARATE PROC ProFee",49000,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,J1630,Haloperidol injection [HCPCS J1630],25,18.75,18.75,14.25,1.08,29.34,,,,,,49002 REOPENING OF RECENT LAPAROTOMY ProFee,49002,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,14.25,7.08,29.34,,,,,,"49203 EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MO ProFee",49203,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.13,0.95,3583.7,,,,,,"49204 EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MO ProFee",49204,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,68.7,52.38,170.1,,,,,,"49320 LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION ProFee",49320,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,129.79,81.71,178.67,,,,,,"49321 LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE) ProFee",49321,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,"49322 LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR ProFee",49322,,,,,
LINE CONSTRUCTION BENEFIT FUND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.82,59.99,274.04,,,,,,"49505 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE ProFee",49505,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Commercial-HMO,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,404.51,166.13,1107.72,,,,,,"49507 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED ProFee",49507,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Commercial-HMO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,0,4.51,1156.79,,,,,,"49520 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE ProFee",49520,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Commercial-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,119.47,61.48,2109.82,,,,,,"49521 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED ProFee",49521,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,359.35,55,3102.09,,,,,,49560 REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; REDUCIBLE ProFee,49560,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.99,2.44,580.94,,,,,,49561 REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR STRANGULATED ProFee,49561,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,0,32.67,218.78,,,,,,"49587 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED ProFee",49587,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,74,20.71,250.4,,,,,,"49650 LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA ProFee",49650,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",653.9,490.43,490.43,202.97,137.3,397.57,,,,,,"49651 LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA ProFee",49651,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.56,8.87,355.2,,,,,,"49652 LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INC ProFee",49652,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,17.14,14.4,297.7,,,,,,"49653 LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INC ProFee",49653,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,0,2.66,76.2,,,,,,"49654 LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFOR ProFee",49654,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,2.25,1.89,53,,,,,,"49655 LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFOR ProFee",49655,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,6.48,5.44,96,,,,,,"51865 CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; COMPLICATED ProFee",51865,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,6.51,5.81,65.1,,,,,,"51992 LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETI ProFee",51992,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,11.55,11.55,98.31,,,,,,52000 CYSTOURETHROSCOPY (SEPARATE PROCEDURE) ProFee,52000,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,11.57,9.72,190.22,,,,,,52700 TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS ProFee,52700,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,6.7,5.63,72.8,,,,,,54150 CIRCUMCISION PLATIBE CHARGE,54150,0723,,361.7,271.275,271.275
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,15.05,12.64,85.85,,,,,,"54160 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; NEONATE (28 ProFee",54160,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.77,6,88.2,,,,,,"54161 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 2 ProFee",54161,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,6.74,6.74,92.02,,,,,,55100 DRAINAGE OF SCROTAL WALL ABSCESS ProFee,55100,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,2.99,2.99,62.24,,,,,,56405 INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS ProFee,56405,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,2.99,2.99,48.11,,,,,,56440 MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST ProFee,56440,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,7.76,7.24,496.86,,,,,,"56442 HYMENOTOMY, SIMPLE INCISION ProFee",56442,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,5.97,5.57,65.1,,,,,,56605 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION ProFee,56605,0960,,486.3,364.725,364.725
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,9.08,8.17,155.5,,,,,,56700 PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING ProFee,56700,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,35.09,29.48,155.5,,,,,,"56810 PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE) ProFee",56810,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,35.09,29.48,155.5,,,,,,"57065 DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSU ProFee",57065,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,57100 BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE) ProFee,57100,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,24.77,19.15,448.97,,,,,,57135 EXCISION OF VAGINAL CYST OR TUMOR ProFee,57135,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,"57200 COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) ProFee",57200,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,"57240 ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE ProFee",57240,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,0,4.51,1156.79,,,,,,"57250 POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY ProFee",57250,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,0,39.1,434.06,,,,,,57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY; ProFee,57260,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,113.76,61.48,2109.82,,,,,,"57288 SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC) ProFee",,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,176.96,50,3116.59,,,,,,57400 DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL) ProFee,57400,,,,,
LOUISIANA HEALTHCARE CONNECTIONS - Medicaid,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,10.86,0.02,4433.9,,,,,,"57420 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; ProFee",57420,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,"57421 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERV ProFee",57421,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,57452 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; ProFee,57452,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,258.3,107.28,315.01,,,,,,57454 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX ProFee,57454,0960,,807.1,605.325,605.325
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,57455 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX ProFee,57455,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,142.73,20.71,250.4,,,,,,57456 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH ENDOCERVICAL CURETTAGE ProFee,57456,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,56.36,23.61,157.86,,,,,,57461 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATI ProFee,57461,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,283.5,89.59,349.41,,,,,,"57500 BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FUL ProFee",57500,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,140.22,8.87,355.2,,,,,,57505 ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE) ProFee,57505,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,62.39,11.25,148.9,,,,,,"57511 CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT ProFee",57511,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.11,2.66,76.2,,,,,,"57520 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETT ProFee",57520,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,74.16,7.58,134.6,,,,,,"57522 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETT ProFee",57522,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,77.35,14.11,134.34,,,,,,"58120 DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL) ProFee",58120,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,"58140 MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TO ProFee",58140,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,7.92,6.79,100.4,,,,,,"58146 MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR ProFee",58146,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,7.91,2.84,108.1,,,,,,"58150 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), ProFee",58150,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,7.93,6.8,52.43,,,,,,"58210 RADICAL ABDOMINAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-A ProFee",58210,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,8.48,7.27,172,,,,,,"58260 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; ProFee",58260,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,50.8,45.82,378.9,,,,,,"58262 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY( ProFee",58262,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.83,6.15,4344.87,,,,,,"58263 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY( ProFee",58263,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,47.12,40.84,136.8,,,,,,"58270 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE ProFee",58270,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,35.11,23.51,98.36,,,,,,"58290 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; ProFee",58290,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,152.94,140.59,428.4,,,,,,"58291 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OV ProFee",58291,,,,,
LUCENT HEALTH SOLUTIONS - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,63.91,62.38,245.75,,,,,,"58292 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OV ProFee",58292,,,,,
MONTANA MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.4,2.44,580.94,,,,,,"58294 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REPAIR OF ENTEROCELE ProFee",,,,,,
MONTANA MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,133.49,8.87,355.2,,,,,,58300 INSERTION OF INTRAUTERINE DEVICE (IUD) ProFee,58300,0960,,345.2,258.9,258.9
MONTANA MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,62.87,8.16,104.31,,,,,,"58350 CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS ProFee",58350,,,,,
MONTANA MEDICAID - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,47.88,6,88.2,,,,,,"58356 ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE, INCLUDING ENDOMETRIAL CURETTAGE, WH ProFee",58356,,,,,
ALLIED BENEFIT SYSTEMS LLC - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,90.77,52.38,170.1,,,,,,"58540 HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) ProFee",58540,,,,,
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Outpatient,99199,"Unlisted procedure, service, or report [HCPCS 99199]",233.1,174.83,174.83,556.5,167.61,8028.2,,,,,,"58545 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGH ProFee",58545,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,305.18,131.45,310.8,,,,,,"58546 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAM ProFee",58546,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,318.54,266.1,323.65,,,,,,"58550 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; ProFee",58550,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,290.62,35.11,337.46,,,,,,"58552 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOV ProFee",58552,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,"58553 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; ProFee",58553,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,258.3,107.28,315.01,,,,,,"58554 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH ProFee",58554,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],415.7,311.78,311.78,359.2,359.2,359.2,,,,,,"58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) ProFee",58555,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,567.82,393.52,2894.06,,,,,,"58558 HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH ProFee",58558,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,70.79,55,166.67,,,,,,"58559 HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD) ProFee",58559,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,8.8,2.44,580.94,,,,,,"58560 HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD) ProFee",58560,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,163.19,119.94,617.26,,,,,,"58561 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA ProFee",58561,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,890.33,137.3,1347.57,,,,,,"58563 HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROS ProFee",58563,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,104.9,20.71,250.4,,,,,,"58600 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, UNILATERA ProFee",58600,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,154.64,28.74,271.3,,,,,,"58605 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, POSTPARTU ProFee",58605,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,754.11,137.3,1124.55,,,,,,58611 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT THE TIME OF CESAREAN DELIVER ProFee,58611,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,94.25,4.45,148.78,,,,,,"58615 OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) VAGINAL OR SUPR ProFee",58615,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,128.25,69.84,223.7,,,,,,"58660 LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE ProFee",58660,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,126.58,4.41,166.13,,,,,,"58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTO ProFee",58661,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72141,Imaging of upper spinal canal by MRI without contrast [HCPCS 72141],1046.4,784.8,784.8,588.71,438.46,588.71,,,,,,"58662 LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VI ProFee",58662,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,588.71,350.85,825.61,,,,,,"58670 LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION) ProFee",58670,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72192,"Pelvis CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 72192]",1221.6,916.2,916.2,511.9,511.9,1221.6,,,,,,"58671 LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR FALOPE ProFee",58671,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,127.42,94.25,222.4,,,,,,"58673 LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY) ProFee",58673,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,94.25,24.39,148.78,,,,,,"58700 SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) ProFee",58700,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,127.42,18.85,148.78,,,,,,"58740 LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) ProFee",58740,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,94.25,33.08,182.07,,,,,,"58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; ProFee",58940,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,127.42,99,166.13,,,,,,59020 FETAL CONTRACTION STRESS TEST ProFee,59020,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,127.42,30.08,220.5,,,,,,59025 FETAL NONSTRESS ProFee,59025,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73501,Hip x-ray of hip with pelvis (single view) [HCPCS 73501],225,168.75,168.75,126.58,49.24,127.42,,,,,,"59120 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGECTOMY AND ProFee",59120,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,128.25,57.76,225,,,,,,59151 LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY ProFee,59151,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,127.42,94.25,214.2,,,,,,"59160 CURETTAGE, POSTPARTUM ProFee",59160,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],225,168.75,168.75,127.42,27.06,225,,,,,,"59300 EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING ProFee",59300,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,128.25,94.25,191.25,,,,,,"59320 CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL ProFee",59320,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,122.09,69.84,225,,,,,,"59400 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY (WITH OR WITHOUT EP ProFee",59400,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,126.58,56.37,178.99,,,,,,59409 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); ProFee,59409,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,128.25,37.7,213.75,,,,,,59410 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); INCLUDING POSTPARTU ProFee,59410,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],1046.4,784.8,784.8,596.45,350.85,636.21,,,,,,59414 DELIVERY OF PLACENTA (SEPARATE PROCEDURE) ProFee,59414,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,94.25,90,225,,,,,,59425 ANTEPARTUM CARE ONLY; 4-6 VISITS ProFee,59425,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1043.2,180.22,3324.06,,,,,,59426 ANTEPARTUM CARE ONLY; 7 OR MORE VISITS ProFee,59426,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1362.81,561.23,2500,,,,,,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE) ProFee,59430,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,236.96,166.13,421.2,,,,,,"59510 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN DELIVERY, AND POSTPARTUM CA ProFee",59510,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,267.16,137.3,401.67,,,,,,59514 CESAREAN DELIVERY ONLY; ProFee,59514,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,367.88,107.93,965.26,,,,,,59515 CESAREAN DELIVERY ONLY; INCLUDING POSTPARTUM CARE ProFee,59515,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",468.7,351.53,351.53,254.39,166.13,311.42,,,,,,"59610 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY (WITH OR WITHOUT EP ProFee",59610,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],485.7,364.28,364.28,273.26,84.74,462.5,,,,,,"59612 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOTOMY AN ProFee",59612,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,67.45,8.49,161,,,,,,"59614 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOTOMY AN ProFee",59614,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,8.87,355.2,,,,,,"59618 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN DELIVERY, AND POSTPARTUM CA ProFee",59618,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,84.87,11.25,148.9,,,,,,"59620 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN D ProFee",59620,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,104.56,8.3,183.45,,,,,,"59622 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN D ProFee",59622,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80202,Lab analysis to measure the amount of vancomycin (antibiotic) in serum specimen [HCPCS 80202],158.8,119.1,119.1,89.61,66.53,120.28,,,,,,"59812 TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY ProFee",59812,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,55,9.63,285.09,,,,,,"59820 TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER ProFee",59820,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,41.33,2.66,76.2,,,,,,"59821 TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER ProFee",59821,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,22.18,1.89,53,,,,,,"59830 TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY ProFee",59830,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],118.1,88.58,88.58,49.46,4.22,71.8,,,,,,"59855 INDUCED ABORTION, BY 1 OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHO ProFee",59855,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82378,Lab analysis to measure the carcinoembryonic antigen (cea) protein level [HCPCS 82378],202.9,152.18,152.18,113.34,85.01,123.36,,,,,,"60699 UNLISTED PROCEDURE, ENDOCRINE SYSTEM ProFee",60699,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,27.28,5.81,65.1,,,,,,"62273 INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH ProFee",62273,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,56.03,11.55,98.31,,,,,,"62320 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC ProFee",62320,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,28.05,5.2,40.9,,,,,,"62322 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC ProFee",62322,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,69.66,12.67,98.39,,,,,,"62324 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMIT ProFee",62324,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,259.92,32.34,465.3,,,,,,"62326 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMIT ProFee",62326,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,3.83,2.66,8.7,,,,,,"64415 INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE ProFee",64415,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,48.53,8.16,104.31,,,,,,"64425 INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES ProFee",64425,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,105.34,9.72,190.22,,,,,,"64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE ProFee",64447,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,65.16,5.07,94.54,,,,,,"69110 EXCISION EXTERNAL EAR; PARTIAL, SIMPLE REPAIR ProFee",69110,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,59.76,5,105.9,,,,,,99024 OFFICE VISIT POST OP ProFee,99024,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,39.5,5.63,72.8,,,,,,99100 ANES EXTREME AGE <1&>70YR ProFee,99100,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,159.3,32.98,268.8,,,,,,99140 EMERGENCY CONDITIONS ProFee,99140,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],61.8,46.35,46.35,34.88,11.39,37.57,,,,,,99217 OBSERVATION CARE DISCHARGE MANAGEMENT ProFee,99217,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,72.68,7.58,134.6,,,,,,99218 LEVEL 1: DETAILED HX/EXAM: STRAIGHTFORWARD 30 MIN ProFee,99218,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,76.58,14.11,134.34,,,,,,99219 LEVEL 2: COMP HX/EXAM: MODERATE 50 MIN ProFee,99219,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,86.87,14.41,153.94,,,,,,99220 LEVEL 3: COMP HX/EXAM: HIGH 70 MIN ProFee,99220,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,79.68,9.87,141.2,,,,,,99221 LEVEL 1 ADMIT STRAIGHTFORWARD 30 MIN ProFee,99221,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,29.91,4.02,32.1,,,,,,99222 LEVEL 2 ADMIT MODERATE 50 MIN ProFee,99222,0987,,326.4,244.8,244.8
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,28.73,4.54,50.4,,,,,,99223 LEVEL 3 HIGHLY COMPLEX 70 MIN ProFee,99223,0987,,403.6,302.7,302.7
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,99231 LEVEL 1 VISIT STABLE IMPROVING 15 MIN ProFee,99231,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,15.71,5.43,37.5,,,,,,99232 LEVEL 2 VISIT MINOR COMPLICATION 25 MIN ProFee,99232,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,108.29,8.55,182.7,,,,,,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 35 MIN ProFee,99233,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,37.73,3.6,69.6,,,,,,99234 LEVEL 1: DETAILED HX/EXAM: STRAIGHTFORWARD SAME DAY 40 MIN ProFee,99234,0987,,343,257.25,257.25
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,38.54,2.7,54.33,,,,,,99235 LEVEL 2: COMP HX/EXAM: MODERATE SAME DAY 50 MIN ProFee,99235,0987,,458.7,344.025,344.025
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,37.73,6.03,69.6,,,,,,99236 LEVEL 3: COMP HX/EXAM: HIGH SAME DAY 55 MIN ProFee,99236,0987,,568.9,426.675,426.675
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,43,5.26,76.2,,,,,,99238 HSP DISCH DAY MGMT 30 MIN ProFee,99238,0987,,329.7,247.275,247.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,79.68,9.2,112.32,,,,,,99239 INPT DSCHRG >30 MIN ProFee,99239,0987,,326.4,244.8,244.8
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,56.66,6.79,100.4,,,,,,99251 INTL INPT CNSLT 20MIN/STFOWARD ProFee,99251,0521,,225,168.75,168.75
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,61,2.84,108.1,,,,,,99252 INTL INPT CNSLT 40MINS/STFOWARD ProFee,99252,0521,,286.7,215.025,215.025
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,13.86,6.8,52.43,,,,,,99253 INTL INPT CNSLT 55 MINS/LOW ProFee,99253,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,97.06,7.27,172,,,,,,99254 INTL INPT CNSLT 80MIN/MOD ProFee,99254,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,87.75,8.17,155.5,,,,,,99255 INTL INPT CNSLT 110MIN/H ProFee,99255,0521,,553.5,415.125,415.125
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],282.3,211.73,211.73,118.27,31.31,118.27,,,,,,99281 BRIEF SERVICE ProFee,99281,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,93.34,45.82,378.9,,,,,,99282 ED PF - Level 2,99282,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,59.85,29.48,105,,,,,,99283 ED PF - Level 3,99283,0981,,234.9,176.175,176.175
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.38,6.15,4344.87,,,,,,99284 ED PF - Level 4,99284,0981,,447.7,335.775,335.775
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,401.36,166.13,1092.27,,,,,,99285 ED PF - Level 5,99285,0981,,657.1,492.825,492.825
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,45.49,19.15,448.97,,,,,,99291 ED PF - CRITICAL CARE Initial,99291,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,252.92,28.6,1161.38,,,,,,99292 ED PF CRITICAL CARE ADDL',99292,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,43.72,16.26,2475.42,,,,,,99304 ADMIT LOW 25 MIN ProFee,99304,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,254.56,68.61,524.17,,,,,,99305 ADMIT MODERATE 35 MIN ProFee,99305,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,43.72,20.72,3197.1,,,,,,99306 ADMIT HIGH 45 MIN ProFee,99306,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,52.5,34.19,143.78,,,,,,99307 VISIT LOW 10 MIN ProFee,99307,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,93.33,4.51,1156.79,,,,,,99308 VISIT MODERATE 15 MIN ProFee,99308,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,108.36,29.4,2785.69,,,,,,99309 VISIT MOD/HIGH 25 MIN ProFee,99309,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,21.55,12.56,48.28,,,,,,99310 VISIT HIGH 35 MIN ProFee,99310,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,21.1,10.24,44.01,,,,,,99315 SWINGBED DIS <30 MINS ProFee,99315,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,63.71,40.84,136.8,,,,,,99316 SWINGBED DIS >30 MINS ProFee,99316,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,47.46,23.51,98.36,,,,,,99356 IF OVER A FULL HOUR ADD TO THE ADMIT CODE ProFee,99356,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,206.7,140.59,428.4,,,,,,99357 EACH ADDITIONAL ½ HOUR AFTER 1ST HOUR ProFee,99357,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,205.35,140.59,241.75,,,,,,99460 INITAL NEWBORN E/M ProFee,99460,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,74.35,40.84,154.11,,,,,,99462 SBSQ NB EM PER DAY HOSP ProFee,99462,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,139.54,39.1,434.06,,,,,,"99463 INI CARE,ADM/DS SAME DY ProFee",99463,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,161.26,61.48,2109.82,,,,,,99464 ATTENDANCE AT DELIVERY OF NEWBORN ProFee,99464,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,238.88,50,3116.59,,,,,,99465 NEWBORN RESUSCITATION CHARGE,99465,0724,,479.7,359.775,359.775
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,508.16,62.92,1098.7,,,,,,10120 ED PF/TECH INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,10120,0450,,865.6,649.2,649.2
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],3736.08,2802.06,2802.06,1246.96,1246.96,1246.96,,,,,,10121 INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL TechFee,10121,0450,,"3,791.6",2843.7,2843.7
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,83.55,2.42,250.2,,,,,,10160 ED TECH/PF PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST,10160,0450,,865.6,649.2,649.2
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0283,Elec stim other than wound [HCPCS G0283],62.9,47.18,47.18,26.36,26.36,35.85,,,,,,11730 ED TECH/PF AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1,11730,0450,,486.3,364.725,364.725
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0328,Fecal blood scrn immunoassay [HCPCS G0328],48.8,36.6,36.6,26.45,20.42,48.31,,,,,,11740 EVACUATION SUBUNGUAL HEMATOMA TechFee,11740,0450,,293.3,219.975,219.975
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,13.76,5.83,3301.98,,,,,,11750 EXCISION NAIL MATRIX PERMANENT REMOVAL TechFee,11750,0450,,865.6,649.2,649.2
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,13.76,7.4,19.63,,,,,,11765 WEDGE EXCISION SKIN NAIL FOLD TechFee,11765,0450,,865.6,649.2,649.2
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,3.56,0.68,2868.2,,,,,,12002 ED TECH & PF SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM,12002,0450,,486.3,364.725,364.725
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,31.64,13.53,65.14,,,,,,16020 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL TechFee,16020,0450,,486.3,364.725,364.725
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,3.56,0.11,332.88,,,,,,16025 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM TechFee,16025,0450,,486.3,364.725,364.725
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,14.25,2.1,2819.66,,,,,,16030 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE TechFee,16030,0450,,865.6,649.2,649.2
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J1650,Inj enoxaparin sodium [HCPCS J1650],14.44,10.83,10.83,0.6,0.47,8.78,,,,,,29105 APPLICATION LONG ARM SPLINT SHOULDER HAND TechFee,29105,0450,,371.6,278.7,278.7
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J1956,Levofloxacin injection [HCPCS J1956],12.5,9.38,9.38,7.13,5.5,16.47,,,,,,29125 ED TECH & PF APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC,29125,0450,,293.3,219.975,219.975
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,14.06,0.73,808.23,,,,,,29126 APPLICATION SHORT ARM SPLINT DYNAMIC TechFee,29126,0450,,293.3,219.975,219.975
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,14.06,7.08,29.34,,,,,,29130 APPLICATION FINGER SPLINT STATIC TechFee,29130,0450,,154.4,115.8,115.8
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,7.03,5.5,14.67,,,,,,29131 APPLICATION FINGER SPLINT DYNAMIC TechFee,29131,0450,,154.4,115.8,115.8
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,11,3.15,30.39,,,,,,29505 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES TechFee,29505,0450,,371.6,278.7,278.7
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,14.16,11,29.34,,,,,,29515 ED PF/TECH APPLICATION SHORT LEG SPLINT CALF FOOT,29515,0450,,371.6,278.7,278.7
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.13,0.95,3583.7,,,,,,90471 IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE TechFee,90471,0450,,5.6,4.2,4.2
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,4.72,1.72,16.28,,,,,,90472 IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE TechFee,90472,0450,,69.6,52.2,52.2
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.55,0.55,29.34,,,,,,G0390 TRAUMA RESPONS W/HOSP CRITI TechFee,G0390,0684,,"2,605.7",1954.275,1954.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,16.58,5.49,347.63,,,,,,MG Mammo Diagnostic Bilateral w/ Tomo.,77066,0401,,485.7,364.275,364.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,7.08,5.5,19.14,,,,,,MG Mammo Diagnostic Left w/ Tomo.,77065,0401,,485.7,364.275,364.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,0,1.66,23.47,,,,,,MG Mammo Diagnostic Right w/ Tomo.,77065,0401,,485.7,364.275,364.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,1.76,23.48,,,,,,MG Mammo Digital Diagnostic Bilat.,77066,0401,,282.3,211.725,211.725
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,0,0.02,4433.9,,,,,,MG Mammo Digital Diagnostic Left.,77065,0401,,260.2,195.15,195.15
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],132.3,99.23,99.23,43.81,43.81,43.81,,,,,,MG Mammo Digital Diagnostic Right.,77065,0401,,260.2,195.15,195.15
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],3522.49,2641.87,2641.87,179.75,179.75,1202.14,,,,,,MG Mammo Digital Screening Bilateral.,77067,0403,,134.5,100.875,100.875
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,69.82,52.38,170.1,,,,,,MG Mammo Digital Screening Left.,77067,0403,,112.5,84.375,84.375
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,93.46,52.53,206.9,,,,,,MG Mammo Digital Screening Right.,77067,0403,,112.5,84.375,84.375
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,129.79,81.71,178.67,,,,,,MG Mammo Screening Bilateral w/ Tomo.,77067,0403,,297.7,223.275,223.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,131.34,95.05,222.03,,,,,,MG Mammo Screening Left w/ Tomo.,77067,0403,,297.7,223.275,223.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.33,22.37,41.75,,,,,,MG Mammo Screening Right w/ Tomo.,77067,0403,,297.7,223.275,223.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,69.53,39.55,134.08,,,,,,MRI Breast w/ + w/o Contrast Bilateral.,77049,0610,,"1,985.7",1489.275,1489.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99226,Subsequent observation care (typically 35 minutes per day) [HCPCS 99226],285.4,214.05,214.05,0,98.08,98.08,,,,,,MRI Breast w/ Contrast Bilateral.,77049,0610,,"2,000",1500,1500
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,MRI Breast w/o Contrast Bilateral.,77047,0610,,"1,985.7",1489.275,1489.275
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,69.53,45.48,91.29,,,,,,US Breast Complete Left.,76641,0402,,421.2,315.9,315.9
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,126.93,114.76,176.55,,,,,,US Breast Complete Right.,76641,0402,,421.2,315.9,315.9
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99235,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235],458.7,344.03,344.03,158.66,142.98,177.83,,,,,,US Breast Limited Left.,76642,0402,,323.1,242.325,242.325
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.82,59.99,274.04,,,,,,US Breast Limited Right.,76642,0402,,323.1,242.325,242.325
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],415.7,311.78,311.78,86.79,86.79,92.46,,,,,,Iron Panel,,0300,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,42.53,41.76,46.23,,,,,,10061 Incision and drainage of abscess; complicated or multiple,10061,0521,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,66.64,66.42,66.64,,,,,,"10120 Incision and removal of foreign body, subcutaneous tissues; simple",10120,0521,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",333,249.75,249.75,0,69.22,77.17,,,,,,"10140 Incision and drainage of hematoma, seroma or fluid collection",10140,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,254.3,131.45,310.8,,,,,,"11042 CLINIC Debridement, subcutaneous tissue; first 20 sq cm or less",11042,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,"11043 Debridement, muscle and/or fascia; first 20 sq cm or less",11043,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,258.3,107.28,315.01,,,,,,11055 Paring or cutting of benign hyperkeratotic lesion; single lesion,11055,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,8.8,2.44,580.94,,,,,,"11104 Biopsy of skin, subcutaneous tissue and/or mucous membrane; single lesion",11102,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",4790.75,3593.06,3593.06,1615.38,1615.38,1615.38,,,,,,"11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions",11200,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,8.87,355.2,,,,,,"11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions",11201,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,"11401 Excision, benign lesion including margins; trunk, arms or legs; 0.6-1.0cm",11401,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,17.96,13.86,24.19,,,,,,"11402 Excision, benign lesion including margins; trunk, arms or legs; 1.1-2.0cm",11402,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,51.3,6.15,4344.87,,,,,,"11422 Excision, benign lesion including margins; scalp, neck, hands, feet, genitalia; 1.1-2.0cm",11422,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,0,10.32,28.14,,,,,,"11423 Excision, benign lesion including margins; scalp, neck, hands, feet, genitalia; 2.1-3.0cm",11423,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.13,0.95,3583.7,,,,,,"11441 Excision, benign lesion including margins; face, ears, eyelids, nose, lips; 0.6-1.0cm",11441,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part A,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.71,0.55,29.34,,,,,,"11442 Excision, benign lesion including margins; face, ears, eyelids, nose, lips; 1.0-2.0cm",11442,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,0,1.64,80.91,,,,,,"11602 CLINIC Excision, malignant lesion including margins, trunk, arms, or legs; 1.1-2.0cm",11602,0521,,,,
NEW ERA LIFE INSURANCE CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,195.09,192.01,343.2,,,,,,"11606 Excision, malignant lesion including margins, trunk, arms, or legs; >4.0cm",11606,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,0,25.34,25.34,,,,,,"11626 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; >4.0cm",11626,0960,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-Indemnity,,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],267,200.25,200.25,0,66.27,734.24,,,,,,"11642 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; 1.1-2.0cm",11642,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,26700,Dislocated hand joint treatment with manipulation (closed treatment) [HCPCS 26700],1296.38,972.29,972.29,118.75,118.75,118.75,,,,,,"11643 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; 2.1-3.0cm",11643,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],3533.3,2649.98,2649.98,0,8.8,16.21,,,,,,"11750 Excision of nail and nail matrix, partial or complete, for permanent removal",11750,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,406.84,86.56,406.84,,,,,,"11976 Removal, implantable contraceptive capsules",11976,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],238.4,178.8,178.8,146.74,104.9,146.74,,,,,,"11981 Clinic Insertion, non-biodegradable drug delivery implant",11981,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,0,151.19,151.19,,,,,,"11982 Removal, non-biodegradable drug delivery implant",11982,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,140.02,140.02,140.02,,,,,,"11983 Removal with reinsertion, non-biodegradable drug delivery implant",11983,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,197.5,197.5,197.5,,,,,,"12001 Simple repair of wounds; scalp, neck, axillae, genitalia, trunk, extremeties; <2.5cm",12001,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,146.74,146.74,146.74,,,,,,"12002 Simple repair of wounds; scalp, neck, axillae, genitalia, trunk, extremeties; 2.6-7.5cm",12002,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,0,7.21,246,,,,,,"12004 Simple repair of wounds; scalp, neck, axillae, genitalia, trunk, extremeties; 7.6-12.5cm",12004,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,0,4.44,4.44,,,,,,"12005 Simple repair of wounds; scalp, neck, axillae, genitalia, trunk, extremeties; 12.6-20.0cm",12005,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],129.2,96.9,96.9,0,17.07,101.94,,,,,,"12011 Simple repair of wounds of face, ears, eyelids, nose, lips, mucous membra; <2.5cm",12011,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,6.71,12.67,,,,,,"12031 Repair, intermediate; wounds of scalp, axillae, trunk, extremities; <2.5cm",12031,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",84,63,63,0,5.31,66.28,,,,,,"12034 Repair, intermediate; wounds of scalp, axillae, trunk, extremities; 7.6-12.5cm",12034,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],182.7,137.03,137.03,0,10.35,80.39,,,,,,"12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; <2.5cm",12041,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],116.6,87.45,87.45,100.98,7.4,100.98,,,,,,"12042 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6-7.5cm",12042,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,0,5.19,5.3,,,,,,"12051 Intermed repair of wounds; face, ears, eyelids, nose, lips, mucous membra; <2.5cm",12051,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.32,13.55,72.8,,,,,,"12052 Intermed repair of wounds; face, ears, eyelids, nose, lips, mucous membra; 2.6-5.0cm",12052,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],176.4,132.3,132.3,221.45,51.36,244.8,,,,,,"13101 Repair, complex, trunk; 2.6 cm to 7.5 cm",13101,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],267,200.25,200.25,365.66,66.27,734.24,,,,,,"13102 Repair, complex, trunk; each additional 5 cm or less",13102,0521,,,,
NEXT LEVEL ADMINISTRATORS - Commercial-PPO,,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],447.7,335.78,335.78,541.6,428.35,1744.38,,,,,,17000 Clinic Destruct premalg lesion; first lesion,17000,0521,,,,
NM MEDICAID - BCBSNM - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,216.54,61.48,2109.82,,,,,,"17340 Cryotherapy (CO2 slush, liquid N2) for acne",17340,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,18,2.44,580.94,,,,,,"19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance",19100,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,1347.57,137.3,1347.57,,,,,,"20005 Incision and drainage of soft tissue abscess, subfascial",20005,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,214.56,20.71,250.4,,,,,,20525 Removal of foreign body in muscle or tendon sheath; deep or complicated,20525,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,595.35,137.3,1124.55,,,,,,"20527 Injection, enzyme, palmar fascial cord (Dupuytren's contracture)",20527,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,595.35,166.13,1309.77,,,,,,"20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)",20552,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,3324.06,180.22,3324.06,,,,,,"20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes)",20600,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,210.78,8.87,355.2,,,,,,"20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (Elbow, Wrist, Ankle)",20605,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,255.15,14.4,297.7,,,,,,"20610 Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance",20610,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,73.71,9.42,73.71,,,,,,"20680 Removal of implant; deep (buried wire, pin, screw, metal band, nail, rod or plate)",20680,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,45.36,1.89,53,,,,,,"21930 Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm",21930,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,55.8,5.81,65.1,,,,,,"22903 Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater",22903,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,90.72,5,105.9,,,,,,"25680 Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation",25680,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,116.28,14.11,134.34,,,,,,29540 Strapping; ankle and/or foot,29540,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,120.96,9.87,141.2,,,,,,"30300 Removal foreign body, intranasal; office type procedure",30300,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,75.6,6,88.2,,,,,,"36590 Removal of tunneled central venous access device, w/sub port/pump,",36590,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,104.94,6.15,4344.87,,,,,,41100 Biopsy of tongue; anterior two-thirds,41100,0521,,,,
NM PUBLIC SCHOOL INSURANCE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,513.09,50,3116.59,,,,,,"43250 EGD flexible, transoral; with removal of tumor(s), polyp(s), or other lesion by hot biopsy",43250,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,18,2.44,580.94,,,,,,43251 Esophagogastroduodenoscopy removal of tumor(s) w/ snare technique,43251,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,401.67,137.3,401.67,,,,,,"43840 Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury",43840,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,210.78,8.87,355.2,,,,,,44005 Enterolysis (freeing of intestinal adhesion) (separate procedure),44005,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,65.25,2.66,76.2,,,,,,44139 Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy,44139,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,82.26,5.44,96,,,,,,"44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)",44180,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,90.72,5,105.9,,,,,,"44207 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy",44207,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,75.6,6,88.2,,,,,,"45020 Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess",45020,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,139.95,8.17,155.5,,,,,,"45171 Excision of rectal tumor, transanal approach; not including muscularis propria",45171,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,148.86,45.82,378.9,,,,,,"45330 Sigmoidoscopy, flexible; dx, with or without collection of specimen(s) by brushing or washing",45330,0960,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,171.09,29.4,2785.69,,,,,,"46060 I&D of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular",46060,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,34.02,12.56,48.28,,,,,,"46945 Hemorrhoidectomy, SINGLE internal, by ligation other than rubber band;",46945,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,209.79,39.1,434.06,,,,,,"47563 Lap, cholecystectomy w/ cholangiography",47563,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,346.41,61.48,2109.82,,,,,,"49255 Omentectomy, epiploectomy, resection of omentum (separate procedure)",49255,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,488.61,50,3116.59,,,,,,"49323 Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity",49323,0521,,,,
NM RETIREE HEALTHCARE AUTHORITY ASO - Commercial-PPO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,11.25,0.95,3583.7,,,,,,49566 Repair recurrent incisional or ventral hernia; incarcerated or strangulated,49566,0521,,,,
OPTUM CARE NETWORK - Commercial-Mut Defined,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,14.03,2.44,580.94,,,,,,49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair,49568,0521,,,,
OPTUM CARE NETWORK - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",225,168.75,168.75,150.28,94.25,180,,,,,,"49585 Repair umbilical hernia, age 5 years or older; reducible",49585,0521,,,,
OPTUM CARE NETWORK - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,164.3,8.87,355.2,,,,,,"49587 Repair umbilical hernia, age 5 years or older; incarcerated or strangulated",49587,0521,,,,
OPTUM CARE NETWORK - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,35.4,4.54,50.4,,,,,,51701 Insertion of non-indwelling bladder catheter,51701,0521,,,,
OPTUM CARE NETWORK - PASADENA - Commercial-HMO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,0,91.42,145.6,,,,,,"54640 Orchiopexy, inguinal approach, with or without hernia repair",54640,0521,,,,
OTHER PAYER UNKN - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,105.9,62.38,245.75,,,,,,56420 Incision and drainage of Bartholin's gland abscess,56420,0521,,,,
OTHER PAYER UNKN - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,165.4,51.31,199.63,,,,,,56605 Biopsy of vulva or perineum; 1 lesion,56605,0521,,,,
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,94.93,59.92,194.57,,,,,,56820 Colposcopy of the vulva;,56820,0521,,,,
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,128.37,95.05,222.03,,,,,,57160 Fitting and insertion of pessary or other intravaginal support device,57160,0521,,,,
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,67.86,45.48,91.29,,,,,,57415 Removal of impacted vaginal foreign body under anesthesia (other than local),57415,0521,,,,
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,68.47,59.99,274.04,,,,,,"57421 Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix",57421,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,44.4,4.51,1156.79,,,,,,57452 Colposcopy of the cervix including upper/adjacent vagina,57452,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,308.91,35.11,337.46,,,,,,57454 Colposcopy of the cervix incl. vagina; w/ biopsy of cervix and endocervical curettage,57454,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,57455 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix,57455,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,57505 Endocervical curettage,57505,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,72197,"Imaging of pelvis by MRI without contrast, followed by contrast [HCPCS 72197]",1974.7,1481.03,1481.03,1118.27,1118.27,1118.27,,,,,,"58100 Endometrial biopsy with or w/o endocer biopsy, w/o cervical dilation, any method",58100,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,128.25,29.4,177.53,,,,,,58300 Insertion of intrauterine device (IUD),58300,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1430.99,561.23,2500,,,,,,58301 Removal of intrauterine device (IUD),58301,0521,,174,130.5,130.5
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,372.72,166.13,529.3,,,,,,"58925 Ovarian cystectomy, unilateral or bilateral",58925,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,91.77,8.49,161,,,,,,59425 Antepartum care only; 4-6 visits,59425,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,59426 Antepartum care only; 7 or more visits,59426,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,0,14.4,297.7,,,,,,"59899 Unlisted procedure, maternity care and delivery",59899,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43,2.66,76.2,,,,,,"65205 Removal of foreign body, external eye; conjunctival superficial",65205,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,"65220 Removal of foreign body, external eye; corneal, without slit lamp",,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,"65222 Removal of foreign body, external eye; corneal, with slit lamp",,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,44.4,4.51,1156.79,,,,,,"67700 Blepharotomy, drainage of abscess, eyelid",67700,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,113.03,29.4,2785.69,,,,,,"69210 Clinic Removal impacted cerumen requiring instrumentation, unilateral",69210,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,63.29,40.84,136.8,,,,,,"92551 Screening test, pure tone, air only",92551,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,69.37,40.84,143.78,,,,,,92567 Tympanometry (impedance testing),92567,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,35.11,23.51,98.36,,,,,,93000 EKG w/ 12+ leads; Tracing/Interp/Report,93000,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,206.7,140.59,428.4,,,,,,"96374 Therapeutic, prophylactic, or diagnostic injection",,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,73.87,40.84,154.11,,,,,,"97602 Remove devitalized tissue from wound, non-selective debridement, w/o anesthesia, per session",97602,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,217.97,61.48,2109.82,,,,,,"99024 Post-op f/u visit, global, included in the surgical package",99024,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.08,0.95,3583.7,,,,,,"99201 Office/Outpatient Visit - New Patient, Level 1",99201,0521,,,,
PHYSICIANS MUTUAL INS.CO - Medicare Part A,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,14.16,2.81,811.33,,,,,,"99202 Office/Outpatient Visit - New Patient, 15-29 MIN",99202,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,72.8,13.55,72.8,,,,,,99203 Office/Outpatient Visit - NP 30-44 MIN,99203,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,105.9,62.38,245.75,,,,,,"99204 Office/Outpatient Visit - New Patient, Level 4 45-59 MIN",99204,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Skilled Nursing Facility,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,244.8,39.1,434.06,,,,,,"99205 Office/Outpatient Visit - New Patient, Level 5 60-74 MIN",99205,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,246,7.21,246,,,,,,"99211 Office/Outpatient Visit - Established Patient, Level 1",99211,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],69.6,52.2,52.2,69.6,2.69,69.6,,,,,,"99212 Office/Outpatient Visit - Established Patient, Level 2 10-19 MIN",99212,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",425.3,318.98,318.98,446.6,187.13,446.6,,,,,,"99213 Office/Outpatient Visit - Established Patient, Level 3 20-29 MIN",99213,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",301.4,226.05,226.05,199.6,132.62,231.48,,,,,,"99214 Office/Outpatient Visit - Established Patient, Level 4 30-39 MIN",99214,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],176.4,132.3,132.3,244.8,51.36,244.8,,,,,,"99215 Office/Outpatient Visit - Established Patient, Level 5 40-54 MIN",99215,0521,,,,
PLANNED ADMINISTRATORS INC - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,20,20,20,,,,,,"99241 Outpatient Consultation, Level 1 Profee",99241,0521,,,,
"ALLIED NATIONAL, INC. - Commercial-PPO",,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,68.46,13.55,72.8,,,,,,"99242 Outpatient Consultation, Level 2 Profee",99242,0521,,,,
"ALLIED NATIONAL, INC. - Commercial-PPO",,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,78.9,62.38,245.75,,,,,,"99243 Outpatient Consultation, Level 3 Profee",99243,0521,,,,
"ALLIED NATIONAL, INC. - Commercial-PPO",,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,112.59,70,166.6,,,,,,"99244 Outpatient Consultation, Level 4 Profee",99244,0521,,,,
"ALLIED NATIONAL, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,300,Peripheral vascular disorders with complications,21336.11,16002.08,16002.08,0,174.72,174.72,,,,,,"99245 Outpatient Consultation, Level 5 Profee",99245,0521,,,,
"ALLIED NATIONAL, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,730,Other male reproductive system diagnoses without complications,468.7,351.53,351.53,0,141.3,428.73,,,,,,"99304 Initial Nursing Facility Care, Low-CLINIC/NH VISIT",99304,0522,,,,
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,"99305 Initial Nursing Facility Care, Moderate",99305,0522,,,,
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,"99306 Initial Nursing Facility Care, High",99306,0522,,,,
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,0,65.1,68.4,,,,,,"99307 Subsequent Nursing Facility Care, Straightforward",99307,0522,,,,
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-PPO,Hospital,Institutional,Outpatient,99199,"Unlisted procedure, service, or report [HCPCS 99199]",233.1,174.83,174.83,167.61,167.61,8028.2,,,,,,"99308 Subsequent Nursing Facility Care, Low",99308,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,0,1.28,46.3,,,,,,"99309 Subsequent Nursing Facility Care, Moderate",99309,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,"99310 Subsequent Nursing Facility Care, High",99310,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,0,55,166.67,,,,,,"99315 Nursing Facility Discharge, < 30 Min",99315,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.68,2.44,580.94,,,,,,"99316 Nursing Facility Discharge, 31+ Min",99316,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,59,20.71,250.4,,,,,,99318 Annual Nursing Facility Assessment,99318,0525,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,0,94.25,214.2,,,,,,"99341 Home Visit, New Patient, Problem Focused",99341,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,0,8.49,161,,,,,,"99342 Home Visit, New Patient, Expanded Problem Focused",99342,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,9.43,8.87,355.2,,,,,,"99344 Home Visit, New Patient, Comprehensive",99344,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,0,14.4,297.7,,,,,,"99345 Home Visit, New Patient, Unstable",99345,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,9.42,73.71,,,,,,"99347 Home Visit, Established Patient, Problem Focused",99347,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,2.83,2.66,76.2,,,,,,"99348 Home Visit, Established Patient, Expanded Problem Focused",99348,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,0,6.2,81.6,,,,,,"99349 Home Visit, Established Patient, Detailed",99349,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,5.81,5.81,65.1,,,,,,"99350 Home Visit, Established Patient, Comprehensive",99350,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,10.34,9.72,190.22,,,,,,"99354 Prolonged Services, Direct Contact, Office; First Hour",99354,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,5.4,5.07,94.54,,,,,,"99381 Preventive Evaluation, New Pt; < 1 Yr",99381,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,6.16,5,105.9,,,,,,"99382 Preventive Evaluation, New Pt; 1-4 Yrs",99382,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],144.5,108.38,108.38,18.63,18.12,87.86,,,,,,"99383 Preventive Evaluation, New Pt; 5-11 Yrs",99383,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,15,14.11,134.34,,,,,,"99384 Preventive Evaluation, New Pt; 12-17 Yrs",99384,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,13.44,12.64,85.85,,,,,,"99385 Preventive Evaluation, New Pt; 18-39 Yrs",99385,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,6.94,6,88.2,,,,,,"99386 Preventive Evaluation, New Pt; 40-64 Yrs",99386,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,12.62,8.17,155.5,,,,,,"99387 Preventive Evaluation, New Pt; 65+ Yrs",99387,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,48.76,45.82,378.9,,,,,,"99391 Preventive Evaluation, Established Pt; < 1 Yr",99391,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,71.91,28.6,1161.38,,,,,,"99392 Preventive Evaluation, Established Pt; 1-4 Yrs",99392,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,"99393 Preventive Evaluation, Established Pt; 5-11 Yrs",99393,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,24.39,4.51,1156.79,,,,,,"99394 Preventive Evaluation, Established Pt; 12-17 Yrs",99394,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,35.57,29.4,2785.69,,,,,,"99395 Preventive Evaluation, Established Pt; 18-39 Yrs",99395,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,50.5,2.2,117.5,,,,,,"99396 Preventive Evaluation, Established Pt; 40-64 Yrs",99396,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,0,39.1,434.06,,,,,,"99397 Preventive Evaluation, Established Pt; 65+ Yrs",99397,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,133.17,61.48,2109.82,,,,,,99468 Initial Neonatal Critical Care; < 28 Days,,,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,212.01,50,3116.59,,,,,,G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination,G0101,0521,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,0,0.95,3583.7,,,,,,G0179 Home Health Re-Certification for Medicare,G0179,0522,,,,
PRESBYTERIAN HEALTH PLAN CENTENNIAL CARE - Medicaid,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,0,2.81,811.33,,,,,,G0180 Home Health Certification for Medicare,G0180,0522,,,,
PRESBYTERIAN HEALTH PLAN INC - Commercial-HMO,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,0,55,125,,,,,,90471 Immunization administration; first vaccine-CLINIC,90471,0521,,,,
PRESBYTERIAN HEALTH PLAN INC - Commercial-HMO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,0,39.1,434.06,,,,,,90472 Immunization administration; each additional vaccine,90472,0521,,,,
PRESBYTERIAN HEALTH PLAN INC - Commercial-HMO,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0,0.73,808.23,,,,,,90473 Immunization administration by intranasal or oral route; first vaccine,90473,0521,,,,
PRESBYTERIAN HEALTH PLAN INC - Commercial-Indemnity,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,0,107.28,315.01,,,,,,"90632 Hepatitis A vaccine, adult dosage, for intramuscular use",90632,0521,,,,
PRESBYTERIAN HEALTH PLAN INC - Commercial-Indemnity,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,0,94.25,222.4,,,,,,"90633 VFC Havrix Hepatitis A vaccine, 2 dose schedule, for intramuscular use",90633,0521,,,,
PRESBYTERIAN HEALTH PLAN INC - Commercial-Indemnity,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,0,6.15,4344.87,,,,,,"90649 HPV vaccine, quadrivalent, over 18",90649,0521,,,,
PRESBYTERIAN HEALTH PLAN INC - Commercial-Indemnity,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,0,61.48,2109.82,,,,,,90651 Vaccine- Gardasil 9,90651,0521,,,,
REEVES EMPLOYEE - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,78.8,12.82,82,,,,,,"90658 Influenza virus vaccine, trivalent, split virus, 3 yrs of age and older, for intramuscular use",90658,0521,,,,
REEVES EMPLOYEE - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,44.1,1.28,46.3,,,,,,"90662 Influenza virus vaccine, split virus, preservative free, for intramuscular use",90662,0521,,,,
REEVES EMPLOYEE - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,0,13.55,72.8,,,,,,90670 Pneumococcal 13-valent conjugate vaccine,90670,0521,,,,
REGENCE BLUESHIELD OF IDAHO - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,139.54,39.1,434.06,,,,,,"90675 Rabies vaccine, for intramuscular use",90675,0521,,,,
RESERVE NATIONAL INSURANCE CO - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,"90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use",90680,0521,,,,
RESERVE NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,1135.64,393.52,2894.06,,,,,,"90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage",90686,0521,,,,
RESERVE NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,52.23,35.11,337.46,,,,,,"90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage",90688,0521,,,,
ALLISON CRANE & RIGGING - Commercial-Indemnity,,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,65.1,65.1,68.4,,,,,,"90691 Typhoid vaccine, over 18",90691,,,,,
SILAC INSURANCE COMPANY - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,"90696 DTaP-IPV, when administered to children 4 through 6 years of age, for intramuscular use",90696,0521,,,,
SILAC INSURANCE COMPANY - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,0,2.66,8.7,,,,,,"90698 DTaP - Hib - IPV (Pentacel), for intramuscular use",90698,0521,,,,
SILAC INSURANCE COMPANY - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,50.27,6,88.2,,,,,,"90702 Vaccine - Diptheria and Tetanus toxoids DT, absorbed <7yrs",90702,,,,,
SILAC INSURANCE COMPANY - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,39.67,3.6,69.6,,,,,,"90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use",90707,0521,,,,
SILAC INSURANCE COMPANY - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,39.67,6.03,69.6,,,,,,"90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use",90710,0521,,,,
SILAC INSURANCE COMPANY - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,"90713 Poliovirus vaccine, inactivated (IPV)",90713,0521,,,,
SILAC INSURANCE COMPANY - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,219.39,61.48,2109.82,,,,,,"90714 Tenivac - Tetanus and diphtheria toxoids (Td), over 18",,,,,,
STAFF BENEFIT MANAGEMENT & ADMINISTRATION - Commercial-PPO,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,41.67,1.28,46.3,,,,,,"90715 Tdap, when administered to individuals 7 years or older, for intramuscular use",90715,0521,,,,
STAFF BENEFIT MANAGEMENT & ADMINISTRATION - Commercial-PPO,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,100.26,45.56,141.93,,,,,,"90716 Varicella virus vaccine, live, for subcutaneous use",90716,0521,,,,
STAFF BENEFIT MANAGEMENT AND ADMIN-ICL 1406 - Commercial-Indemnity,,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],447.7,335.78,335.78,0,428.35,1744.38,,,,,,"90723 DTaP-HepB-IPV (Pediarix), for intramuscular use",90723,0521,,,,
STAFF BENEFIT MANAGEMENT AND ADMIN-ICL 1406 - Commercial-PPO,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,141.93,45.56,141.93,,,,,,"90732 Pneumococcal polysaccharide vaccine, 23-valent, for subcutaneous or intramuscular use",90732,0521,,,,
SUPERIOR HEALTH - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,"90734 Meningococcal conjugate vaccine, quadrivalent, for intramuscular use",90734,0521,,,,
SUPERIOR HEALTH - Commercial-PPO,Hospital,Institutional,Inpatient,159,Dental & oral diseases without complications,6084.99,4563.74,4563.74,115.65,115.65,283.54,,,,,,"90736 Zoster (shingles) vaccine, live, for subcutaneous injection",90736,0521,,,,
SUPERIOR HEALTH - Commercial-PPO,Hospital,Institutional,Inpatient,885,Mental Illness [MSDRG 885],947.4,710.55,710.55,182.26,126.93,705.12,,,,,,"90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use",90744,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,0,4.8,352,,,,,,90746 Vaccine - Hepatitis B Adult Vaccine,90746,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,1960,Anesthesia provided during vaginal delivery [HCPCS 01960],139,104.25,104.25,296.76,1.24,296.76,,,,,,"96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular",96372,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,1961,Anesthesia provided during cesarean delivery [HCPCS 01961],139,104.25,104.25,329.73,5.74,329.73,,,,,,"J0171 Injection, adrenalin, epinephrine",J0171,0636,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,13.59,3.36,245.34,,,,,,"J0558 Injection, penicillin g benzathine and penicillin g procaine, 100,000 U",,,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],2617.4,1963.05,1963.05,0,627.82,973.08,,,,,,"J0561 Injection, penicillin g benzathine, 100,000 units",J0561,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,49652,Abdominal or navel hernia repair with endoscope (herniated tissue that is not trapped) [HCPCS 49652],2678.1,2008.58,2008.58,579.78,579.78,579.78,,,,,,"J0696 Injection, ceftriaxone sodium, per 250 mg",J0696,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,79.71,79.43,766.3,,,,,,"J1030 Injection, methylprednisolone acetate, 40 mg",J1030,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,58615,Fallopian tubes tying by device through vagina or incision in pubic hairline [HCPCS 58615],1148.8,861.6,861.6,102.11,102.11,388.23,,,,,,"J1050 Injection, medroxyprogesterone acetate, 1 mg",J1050,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,22.99,22.99,68.3,,,,,,"J1071 Injection, testosterone cypionate 1mg",J1071,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,583.91,583.91,1462.85,,,,,,"J1100 Injection, dexamethasone sodium phosphate, 1mg",J1100,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,660.25,138.2,1470.79,,,,,,"J1200 Injection, diphenhydramine hcl, up to 50 mg",J1200,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,"J1885 Injection, ketorolac tromethamine, per 15 mg",J1885,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,0,5.3,61.31,,,,,,"J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg",J1950,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,0,12.82,82,,,,,,"J2550 Injection, promethazine hcl, up to 50 mg",J2550,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,0,1.28,46.3,,,,,,"J2765 Injection, metoclopramide hcl, up to 10 mg",J2765,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,0,5.3,5.3,,,,,,"J2930 Injection, methylprednisolone sodium succinate, up to 125 mg",J2930,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",5.3,3.98,3.98,0,5.3,5.3,,,,,,"J3301 Injection, triamcinolone acetonide, not otherwise specified, 40 mg",J3301,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,0,85.05,170.1,,,,,,"J3410 Injection, hydroxyzine hcl, up to 25 mg",J3410,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,0,134.02,193.88,,,,,,"J3420 Injection, vitamin b-12, up to 1000mcg",J3420,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,214.38,214.38,2255.8,,,,,,"J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg",J7298,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,0,5.19,5.3,,,,,,J7300 Intrauterine copper contraceptive,J7300,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99140,Anesthetic treatment complicated by emergency condition [HCPCS 99140],139,104.25,104.25,0,70.32,70.32,,,,,,"J7301 Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg",,,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,0,91.42,145.6,,,,,,"J7307 Etonogestrel (contraceptive) implant system, including implant and supplies",J7307,0636,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,22.59,13.55,72.8,,,,,,"J7613 Albuterol, inhalation solution, non-compounded, administered through dme, unit dose, 1 mg",J7613,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,"J7614 Levalbuterol, inhalation solution, non-compounded, administered through dme, unit dose, 0.5 mg",J7614,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,58.08,52.38,170.1,,,,,,"J9260 Methotrexate sodium, 50 mg",J9260,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,52.53,52.53,206.9,,,,,,Ear Irrigation POC,69209,,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,90.59,81.71,178.67,,,,,,Influenza A/B POC,87804,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,95.05,95.05,222.03,,,,,,"Q0111 Wet mounts, including preparations of vaginal, cervical or skin specimens",87210,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,22.37,22.37,41.75,,,,,,Urine Dipstick POC,81002,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,31.68,31.68,51.15,,,,,,90648 Hib PRP-T Conjugate 4 dose schedule IM.,90648,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,45.48,45.48,91.29,,,,,,J7644 Ipratropium Bromide Inhalation Solution non compounded,J7644,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,60.51,59.99,274.04,,,,,,90648 VFC Hib PRP-T Conjugate 4 dose schedule IM,90648,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,236.82,65.1,245.75,,,,,,90651 VFC Vaccine- Gardasil 9,90651,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,236.82,55.34,245.75,,,,,,90670 VFC pneumococcal 13-valent conjugate vaccine,90670,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,236.82,65.1,245.75,,,,,,"90680 VFC Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use",90680,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,"90696 VFC DTaP-IPV, when administered to children 4 through 6 years of age, for intramuscular use",90696,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,"90698 VFC DTaP - Hib - IPV (Pentacel), for intramuscular use",90698,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,80.36,77,101.03,,,,,,"90700 VFC DAPTACEL DTaP, under 7 years, for IM use ",90700,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,38.82,38.82,44.36,,,,,,"90707 VFC Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use",90707,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,"90710 VFC Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use",90710,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,,Professional,Outpatient,T1015,Clinic service [HCPCS T1015],105.9,79.43,79.43,245.75,215.52,245.75,,,,,,"90713 VFC Poliovirus vaccine, inactivated (IPV)",90713,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,8.2,5.03,33.1,,,,,,"90715 VFC Tdap, when administered to individuals 7 years or older, for intramuscular use",90715,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,"90716 VFC Varicella virus vaccine, live, for subcutaneous use",90716,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,0,18.04,43.1,,,,,,"90723 VFC DTaP-HepB-IPV (Pediarix), for intramuscular use",90723,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,0,18.04,43.1,,,,,,"90734 VFC Meningococcal conjugate vaccine, quadrivalent, for intramuscular use",90734,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,0,4.42,42.84,,,,,,"90744 VFC Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use",90744,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,13.58,5.2,40.9,,,,,,90471 VFC Immunization administration; first vaccine,90471,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,6.51,3.99,48.28,,,,,,90472 VFC Immunization administration; each additional vaccine,90472,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,10.01,5.07,94.54,,,,,,"90633 Havrix Hepatitis A vaccine, 2 dose schedule, for intramuscular use",90633,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,0,13.86,33.1,,,,,,"90702 VFC Diptheria and Tetanus toxoids DT, absorbed <7yrs",90702,0521,,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,7.85,4.75,40.9,,,,,,93017 STRESS TEST CHARGE,93017,0482,,469.7,352.275,352.275
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,7.89,7.89,28.7,,,,,,Fetal Fibronectin Ref,82731,0300,,465.3,348.975,348.975
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,Gabapentin Ref,80299,0300,,233.8,175.35,175.35
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,0,18.48,44.1,,,,,,30300 REMOVAL NASAL FOREIGN BODY-ER SERV PROCE,30300,0450,,293.3,219.975,219.975
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,7.1,4.35,39.58,,,,,,30901 ED PF/TECH CONTROL ANT. NASAL HEMORRHAGE,30901,0450,,293.3,219.975,219.975
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,0,5.83,44.1,,,,,,"30903 CONTROL ANT. NASAL HEMOR,COMP- ER SERV P",30903,0450,,293.3,219.975,219.975
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,10.48,4.02,32.1,,,,,,63323-0180-01 - pyridoxine 100 mg/mL Inj Sol [REEV],J3415,0250,63323-0180-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",92.7,69.53,69.53,0,5.3,236.82,,,,,,00378-9123-98 - fentaNYL 75 mcg/hr Transderm ER Film [REEV],,0250,00378-9123-98,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,105.86,105.86,1389.2,,,,,,51079-0985-20 - busPIRone 5 mg Tab [REEV],,0250,51079-0985-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],564.9,423.68,423.68,0,336.44,339.56,,,,,,68084-0591-01 - isosorbide mononitrate 30 mg ER Tab [REEV],,0250,68084-0591-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,0,231.95,364.61,,,,,,00406-0484-62 - acetaminophen-codeine 300 mg-30 mg Tab [REEV],,0250,00406-0484-62,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99310,Subsequent nursing facility visit for patient that is unstable or may have develped a major new problem requiring immediate physician attention (typically 35 minutes per day) [HCPCS 99310],617.4,463.05,463.05,0,260.49,344.18,,,,,,00904-3233-92 - calcium-vitamin D 600 mg-400 intl units oral tablet [REEV],,0250,00904-3233-92,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99384,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99384],65.1,48.83,48.83,240.69,65.1,240.69,,,,,,64980-0301-30 - hydrocortisone Top 2.5% Crm [REEV],,0250,64980-0301-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,240.69,65.1,240.69,,,,,,24385-0390-10 - phenylephrine nasal 1% Sol 30 mL [REEV],,0250,24385-0390-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,240.69,65.1,240.69,,,,,,00074-4378-05 - cisatracurium 2 mg/mL IV Sol [REEV],,0250,00074-4378-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],65.1,48.83,48.83,240.69,68.4,240.69,,,,,,00003-0293-28 - triamcinolone 400. Susp,J3301,0250,00003-0293-28,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,240.69,240.69,240.69,,,,,,50419-0423-01 - levonorgestrel 52 mg intrauteral Dev PHS [REEV],J7298,0250,50419-0423-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,0,6.13,13.93,,,,,,24385-0517-26 - brompheniramine-phenylephrine 1 mg-2.5 mg/5 mL oral Liq 118 mL [REEV],,0250,24385-0517-26,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,0,1.1,3.07,,,,,,51079-0644-20 - cyclobenzaprine 10 mg Tab [REEV],,0250,51079-0644-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0,0.63,1.44,,,,,,00169-1833-11 - insulin regular human recombinant 100 units/mL Inj Sol [REEV],J1815,0250,00169-1833-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,0,4,9.09,,,,,,68084-0198-11 - lisinopril 20 mg Tab [REEV],,0250,68084-0198-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,J2997,Alteplase recombinant [HCPCS J2997],183.67,137.75,137.75,0,80.82,80.82,,,,,,00093-3125-01 - dicloxacillin 500 mg Cap [REEV],,0250,00093-3125-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,J7307,Etonogestrel implant system [HCPCS J7307],628.5,471.38,471.38,628.5,628.5,1051.25,,,,,,42023-0124-01 - dantrolene 25 mg Cap [REEV],,0250,42023-0124-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Institutional,Outpatient,T1015,Clinic service [HCPCS T1015],105.91,79.43,79.43,245.75,240.69,245.75,,,,,,10147-0911-01 - haloperidol 5 mg/mL Inj Sol [REEV],J1630,0250,10147-0911-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,49884-0907-38 - megestrol 40 mg/mL Oral Susp [REEV],,0250,49884-0907-38,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,0,5.3,5.3,,,,,,68180-0121-01 - cephalexin 250 mg Cap [REEV],,0250,68180-0121-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",5.3,3.98,3.98,0,5.3,5.3,,,,,,68084-0482-01 - levofloxacin 500 mg Tab [REEV],,0250,68084-0482-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,90632,Hepatitis A vaccine for injection into muscle (adult dosage) [HCPCS 90632],210.5,157.88,157.88,0,89.71,89.71,,,,,,55513-0003-04 - darbepoetin alfa 40 mcg/mL Inj Sol (PHS) [REEV],J0882,0250,55513-0003-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,22.59,13.55,72.8,,,,,,00904-5794-61 - metFORMIN 500 mg ER Tab [REEV],,0250,00904-5794-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,50383-0824-16 - sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [REEV],,0250,50383-0824-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],68.4,51.3,51.3,236.82,68.4,240.69,,,,,,51079-0418-20 - temazepam 15 mg Cap [REEV],,0250,51079-0418-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99383,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99383],68.4,51.3,51.3,231.95,231.95,231.95,,,,,,24208-0720-02 - dexamethasone Ophth 0.1% Sol [REEV],,0250,24208-0720-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,236.82,65.1,245.75,,,,,,00270-0445-35 - diatrizoate meglumine-diatrizoate sodium 66%-10% oral and rectal Sol [REEV],,0255,00270-0445-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,236.82,55.34,245.75,,,,,,10481-0112-08 - ferric subsulfate Top Sol [REEV],,0250,10481-0112-08,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,236.82,65.1,245.75,,,,,,51862-0454-04 - cloNIDine 0.2 mg/24 hr Transderm ER Film [REEV],,0250,51862-0454-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,00406-0484-01 - acetaminophen-codeine 300 mg-30 mg Tab (6pk) [REEV],,0250,00406-0484-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Clinic,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,55150-0154-10 - acyclovir 50 mg/mL IV Sol [REEV],J0133,0250,55150-0154-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,214.38,214.38,2255.8,,,,,,50268-0597-15 - NIFEdipine 30 mg ER Tab [REEV],,0250,50268-0597-15,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,1373,Major respiratory infections & inflammations [Major Severity],15671.08,11753.31,11753.31,15671.08,15671.08,15671.08,,,,,,00713-0280-31 - bacitracin Top 500 units/g Oint [REEV],,0250,00713-0280-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,1374,Major respiratory infections & inflammations [Catastrophic Severity],22218.5,16663.88,16663.88,22218.5,22218.5,22218.5,,,,,,00409-4777-23 - ciprofloxacin 200 mg/100 mL IV Sol [REEV],J0744,0250,00409-4777-23,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,1412,Asthma [Moderate Severity],14162.51,10621.88,10621.88,11001.38,11001.38,11001.38,,,,,,42023-0118-01 - trimethobenzamide 100 mg/mL IM Sol [REEV],J3250,0250,42023-0118-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,3832,Cellulitis & other skin infections [Moderate Severity],8105.42,6079.07,6079.07,6672.06,6672.06,7248.03,,,,,,60267-0812-00 - sodium nitrite-sodium thiosulfate 30 mg-250 mg/mL [REEV],,0250,60267-0812-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,391,"Esophagitis, gastroent & misc digest disorders with major complications",19666.17,14749.63,14749.63,10409.97,87.23,10409.97,,,,,,"60793-0701-10 - penicillin G benzathine 1,200,000 units/2 mL Sus [REEV]",J0561,0250,60793-0701-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,4632,Kidney & urinary tract infections [Moderate Severity],11441.58,8581.19,8581.19,11567.73,11567.73,11567.73,,,,,,00536-1107-88 - nicotine 14 mg/24 hr Transderm ER Film [REEV],,0250,00536-1107-88,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,4691,Acute Kidney Injury # [Minor Severity],1162.2,871.65,871.65,10373.68,10373.68,10373.68,,,,,,63739-0478-10 - docusate sodium 100 mg Cap [REEV],,0250,63739-0478-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5401,Cesarean delivery [Minor Severity],1162.2,871.65,871.65,9934.47,9934.47,10223.07,,,,,,55513-0740-10 - etelcalcetide 2.5 mg/mL [REEV],J0606,0250,55513-0740-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5402,Cesarean delivery [Moderate Severity],43188.08,32391.06,32391.06,16450.64,11506.32,16450.64,,,,,,24208-0635-62 - hydrocortisone/neomycin/polymyxin B Otic Susp [REEV],,0250,24208-0635-62,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5403,Cesarean delivery [Major Severity],12365.98,9274.49,9274.49,10410.7,10410.7,12736.96,,,,,,00641-1397-35 - chlorproMAZINE 25 mg/mL Inj Sol [REEV],J3230,0250,00641-1397-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5411,Vaginal delivery w sterilization &/or D&C [Minor Severity],9919.2,7439.4,7439.4,10377.59,10377.59,10377.59,,,,,,37000-0024-04 - psyllium 3.4 g/5.8 g Oral Pwdr [REEV],,0250,37000-0024-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5412,Vaginal delivery w sterilization &/or D&C [Moderate Severity],11514.56,8635.92,8635.92,11471.97,11471.97,11640.49,,,,,,00074-1658-05 - paricalcitol 5 mcg/mL IV Sol (PHS) [REEV],J2501,0250,00074-1658-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5601,Vaginal delivery [Minor Severity],581.1,435.83,435.83,6384.37,3693.45,6384.37,,,,,,00517-5601-25 - hydrOXYzine hydrochloride 50 mg/mL 1 mL IM Sol [REEV],J3410,0250,00517-5601-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5602,Vaginal delivery [Moderate Severity],581.1,435.83,435.83,7272.33,3623.48,7272.33,,,,,,00904-6461-61 - promethazine 25 mg Tab [REEV],,0250,00904-6461-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5612,Postpartum & post abortion diagnoses w/o procedure [Moderate Severity],12218.97,9164.23,9164.23,8564.5,8564.5,8564.5,,,,,,45802-0174-53 - menthol-methyl salicylate topical 10%-15% Cre [REEV],,0250,45802-0174-53,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5663,Other antepartum diagnoses [Major Severity],17327.79,12995.84,12995.84,11248.37,1162.66,11248.37,,,,,,65162-0752-10 - benazepril 10 mg Tab [REEV],,0250,65162-0752-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,5811,"Neonate, transferred < 5 days old, born here [Minor Severity]",2301.95,1726.46,1726.46,2147.42,2147.42,2147.42,,,,,,68084-0666-01 - metoprolol 50 mg ER Tab [REEV],,0250,68084-0666-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,6141,Neonate bwt 1500-1999g w or w/o other significant condition [Minor Severity],3206.85,2405.14,2405.14,3907.73,3907.73,3907.73,,,,,,00093-3044-01 - verapamil 180 mg ER Tab [REEV],,0250,00093-3044-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,6262,"Neonate bwt 2000-2499g, normal newborn or neonate w other problem [Moderate Severity]",1671.19,1253.39,1253.39,4869.05,4869.05,4869.05,,,,,,17478-0100-02 - cyclopentolate Ophth 1% Sol [REEV],,0250,17478-0100-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,6263,"Neonate bwt 2000-2499g, normal newborn or neonate w other problem [Major Severity]",2215.08,1661.31,1661.31,12344.27,12344.27,12344.27,,,,,,00713-0164-12 - acetaminophen 325 mg Supp [REEV],,0250,00713-0164-12,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,6341,"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond [Minor Severity]",1084.79,813.59,813.59,15214.41,15214.41,15214.41,,,,,,00065-0644-35 - tobramycin Ophth 0.3% Oint [REEV],,0250,00065-0644-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,6401,"Neonate birthwt >2499g, normal newborn or neonate w other problem [Minor Severity]",650.6,487.95,487.95,1559.04,1559.04,1559.04,,,,,,58468-0123-01 - doxercalciferol 2 mcg/mL Inj Sol (PHS) [REEV],,0250,58468-0123-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,6402,"Neonate birthwt >2499g, normal newborn or neonate w other problem [Moderate Severity]",1876.68,1407.51,1407.51,2573.63,1932.98,3273.21,,,,,,00904-1988-61 - acetaminophen 500 mg Tab [REEV],,0250,00904-1988-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,6631,Other anemia & disorders of blood & blood-forming organs [Minor Severity],14537.37,10903.03,10903.03,9478.52,9478.52,9478.52,,,,,,00703-9514-03 - sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol 10 mL [REEV],,0250,00703-9514-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,7202,Septicemia & disseminated infections [Moderate Severity],19576.67,14682.5,14682.5,14503.33,9768.47,14503.33,,,,,,76045-0010-10 - HYDROmorphone 2 mg/mL Inj Sol [REEV],J1170,0250,76045-0010-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,7203,Septicemia & disseminated infections [Major Severity],23741.16,17805.87,17805.87,24195.8,24195.8,24195.8,,,,,,68084-0531-01 - QUEtiapine 50 mg oral tablet [REEV],,0250,68084-0531-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Inpatient,7204,Septicemia & disseminated infections [Catastrophic Severity],9108.97,6831.73,6831.73,5844.81,5844.81,5844.81,,,,,,00904-5495-46 - nitroglycerin 0.2 mg/hr Transderm ER Film [REEV],,0250,00904-5495-46,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,73.01,55,3102.09,,,,,,00005-0100-05 - meningococcal group B vaccine fully recombinant Sus (PHS) [REEV],,0250,00005-0100-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,393.52,393.52,2894.06,,,,,,00406-8315-62 - morphine ER 15 mg tab [REEV],,0250,00406-8315-62,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,11730,Nail plate removal (single nail plate) [HCPCS 11730],486.3,364.73,364.73,106.64,106.64,106.64,,,,,,00904-5923-61 - haloperidol 1 mg Tab [REEV],,0250,00904-5923-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,87.62,55,125,,,,,,45802-0730-30 - acetaminophen 650 mg Supp [REEV],,0250,45802-0730-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,107.31,55,166.67,,,,,,00904-6550-61 - propranolol 10 mg Tab [REEV],,0250,00904-6550-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,12004,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (7.6 to 12.5 cm) [HCPCS 12004]",863.04,647.28,647.28,119.35,76,119.35,,,,,,00409-4282-02 - lidocaine 2% PF Inj Sol 10 mL [REEV],J2001,0250,00409-4282-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,106.98,55,125,,,,,,63739-0694-57 - lidocaine oral 2% Sol 15 mL [REEV],,0250,63739-0694-57,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,12013,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.6 to 5.0 cm) [HCPCS 12013]",469.98,352.49,352.49,111.73,55,111.73,,,,,,00904-6405-06 - azithromycin 250 mg Tab [REEV],,0250,00904-6405-06,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,16020,Burn tissue dressing change and/or removal (small: less than 5% of total body surface area) [HCPCS 16020],709,531.75,531.75,76.01,76.01,76.01,,,,,,24385-0118-78 - simethicone 80 mg Chew Tab [REEV],,0250,24385-0118-78,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,17250,Chemical agent application to wound tissue [HCPCS 17250],709,531.75,531.75,205.89,205.89,468.8,,,,,,00781-3124-95 - nafcillin 1 g Inj [REEV],,0250,00781-3124-95,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,22903,Abdominal wall tissue tumor removal beneath the skin (3 cm or greater) [HCPCS 22903],4557.72,3418.29,3418.29,704.66,704.66,704.66,,,,,,00054-0057-46 - digoxin 50 mcg/mL (0.05 mg/mL) Oral Elix (bottle) [REEV],,0250,00054-0057-46,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,23650,Dislocated shoulder treatment with manipulation (closed treatment) [HCPCS 23650],2934.6,2200.95,2200.95,105.48,105.48,105.48,,,,,,00409-1886-02 - levETIRAcetam 100 mg/mL IV Sol [REEV],J1953,0250,00409-1886-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,4.8,2.44,580.94,,,,,,00121-1761-30 - Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Oral Susp 30 mL [REEV],,0250,00121-1761-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,0,494.34,1384.62,,,,,,"00065-0530-01 - Ophth irrigation, extraocular Sol [REEV]",,0250,00065-0530-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,36600,Collection of blood specimen from arterial puncture for diagnosis [HCPCS 36600],293.6,220.2,220.2,39.78,39.78,171.67,,,,,,"00074-3641-03 - leuprolide 3.75 mg/month IM Inj, (PHS) [REEV]",J1950,0250,00074-3641-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],11326.9,8495.18,8495.18,0,2696.69,4250.36,,,,,,00168-0035-01 - vitamin A & D Top Oint [REEV],,0250,00168-0035-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,47562,Gallbladder removal with an endoscope [HCPCS 47562],8595.17,6446.38,6446.38,1272.13,390,1272.13,,,,,,63323-0424-05 - flumazenil 0.1 mg/mL IV Sol MDV [REEV],J3490,0250,63323-0424-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,49505,Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505],10239.44,7679.58,7679.58,1387.81,390,3515.07,,,,,,00338-0125-04 - Dextrose 5% in Lactated Ringers IV Sol 1000 mL [REEV],,0250,00338-0125-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,49652,Abdominal or navel hernia repair with endoscope (herniated tissue that is not trapped) [HCPCS 49652],14949.2,11211.9,11211.9,1272.13,1272.13,1272.13,,,,,,00338-0704-34 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [REEV],,0250,00338-0704-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,617.26,119.94,617.26,,,,,,00143-9924-90 - ceFAZolin 1 g Inj [REEV],J0690,0250,00143-9924-90,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],361.7,271.28,271.28,73.08,73.08,424.53,,,,,,00074-1658-01 - paricalcitol 5 mcg/mL IV Sol [REEV],J2501,0250,00074-1658-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,57522,Cervix removal or destruction by electrical cautery [HCPCS 57522],6102.71,4577.03,4577.03,1387.81,1387.81,1387.81,,,,,,61703-0350-38 - methotrexate 25 mg/mL Inj Sol [REEV],J9260,0250,61703-0350-38,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],6338.06,4753.55,4753.55,1272.13,1272.13,4240.7,,,,,,00781-3207-85 - cefTRIAXone 500. mg Powder-Inj,J0696,0250,00781-3207-85,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,58671,Blocking of uterine tubes by device with endoscope [HCPCS 58671],7193.76,5395.32,5395.32,1272.13,1272.13,5022.14,,,,,,00338-0043-03 - Sodium Chloride 0.45% IV Sol 500 mL [REEV],,0250,00338-0043-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],339.6,254.7,254.7,81.5,81.5,323.4,,,,,,63402-0512-24 - levalbuterol 0.63,,0250,63402-0512-24,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,59320,Cervical suture through vagina during pregnancy [HCPCS 59320],3933.62,2950.22,2950.22,1049.53,1049.53,1357.77,,,,,,00378-5110-01 - prochlorperazine 10 mg Tab [REEV],,0250,00378-5110-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,32.67,32.67,218.78,,,,,,00591-0794-01 - dicyclomine 10 mg Cap [REEV],,0250,00591-0794-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70100,"Lower jaw x-ray, partial study (less than 4 views) [HCPCS 70100]",228.3,171.23,171.23,123.34,123.34,123.34,,,,,,00004-0800-85 - oseltamivir 75 mg Cap [REEV],,0250,00004-0800-85,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70110,"Lower jaw x-ray, complete study (minimum of 4 views) [HCPCS 70110]",225,168.75,168.75,162.01,162.01,162.01,,,,,,00409-4684-13 - fluconazole 200 mg/100 mL-D5W IV Sol [REEV],J1450,0250,00409-4684-13,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70140,Facial bones x-ray for injuries or lesions (less than 3 views) [HCPCS 70140],225,168.75,168.75,123.34,123.34,148.78,,,,,,00409-4332-01 - vancomycin 500. mg Powder-Inj,J3370,0250,00409-4332-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70150,Facial bones x-ray for injuries or lesions (minimum of 3 views) [HCPCS 70150],225,168.75,168.75,166.13,136.8,166.13,,,,,,00409-5534-34 - sodium bicarbonate 4.2% IV Sol 10 mL [REEV],,0250,00409-5534-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70160,Nasal bones x-ray taken from side to side for complete exam (minimum of 3 views) [HCPCS 70160],225,168.75,168.75,123.34,31.08,123.34,,,,,,66993-0022-27 - levalbuterol 0.63 mg/3 mL Inh Sol [REEV],J7614,0250,66993-0022-27,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70250,Skull bones x-ray (less than 4 views) [HCPCS 70250],225,168.75,168.75,166.13,166.13,166.13,,,,,,00121-0431-30 - magnesium hydroxide 8% Oral Susp 30 mL [REEV],,0250,00121-0431-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,166.13,137.3,1347.57,,,,,,42292-0018-20 - clindamycin 150 mg Cap [REEV],,0250,42292-0018-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70480,"Skull CT scan to examine the bones of the eye and ear without contrast to examine injury, foreign bodies, or tumors [HCPCS 70480]",1313.2,984.9,984.9,166.13,166.13,166.13,,,,,,31722-0542-01 - indomethacin 25 mg Cap [REEV],,0250,31722-0542-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,73.48,73.48,1221.85,,,,,,00641-6103-25 - methocarbamol 100 mg/mL Inj Sol [REEV],,0250,00641-6103-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70490,"Neck CT scan of the soft tissue of the neck without contrast to examine injury, foreign bodies, or tumors [HCPCS 70490]",1156.6,867.45,867.45,166.13,166.13,703.21,,,,,,68084-0658-01 - ibuprofen 400 mg Tab [REEV],,0250,68084-0658-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",1974.7,1481.03,1481.03,561.23,561.23,1308.35,,,,,,00143-9787-10 - enalapril 1.25 mg/mL IV Sol [REEV],J3490,0250,00143-9787-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,123.34,20.71,250.4,,,,,,63323-0346-10 - cefTRIAXone 1. g Powder-Inj,J0696,0250,63323-0346-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,123.34,28.74,271.3,,,,,,68084-0683-01 - DULoxetine 30 mg Cap [REEV],,0250,68084-0683-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,123.34,94.25,177.23,,,,,,00904-5306-60 - diphenhydrAMINE 25. mg Cap,,0250,00904-5306-60,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,166.13,109.96,166.13,,,,,,00409-7809-24 - DOPamine 160 mg/100 mL-D5% 800.,J1265,0250,00409-7809-24,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71110,Rib cage x-ray of ribs on both sides of body (3 views) [HCPCS 71110],236,177,177,166.13,103.84,166.13,,,,,,24385-0061-03 - bacitracin/neomycin/polymyxin B Top Oint (tube) [REEV],,0250,24385-0061-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,166.13,137.3,1124.55,,,,,,00409-4276-16 - lidocaine 1% 20 mL MDV Inj Sol [REEV],J2001,0250,00409-4276-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,272.21,272.21,1200.54,,,,,,25021-0132-81 - levofloxacin 250 mg/50 mL IV Sol [REEV],J1956,0250,25021-0132-81,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1412.4,1059.3,1059.3,272.21,272.21,898.39,,,,,,"49281-0190-10 - rabies immune globulin, human 150 intl units/mL IM Sol [REEV]",,0250,49281-0190-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,123.34,4.45,148.78,,,,,,00006-0112-31 - sitaGLIPtin 50 mg oral tablet [REEV],,0250,00006-0112-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72080,Spinal x-ray of junction of middle and lower spine (2 views) [HCPCS 72080],121.3,90.98,90.98,123.34,68.69,123.34,,,,,,00378-9102-93 - nitroglycerin 0.1 mg/hr Transderm ER Film [REEV],,0250,00378-9102-93,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72082,Spinal x-ray of entire middle and lower spine (may also include skull and upper spine) for scoliosis detection (2 or 3 views) [HCPCS 72082],506.1,379.58,379.58,166.13,166.13,166.13,,,,,,59762-5021-01 - quinapril 20 mg Tab [REEV],,0250,59762-5021-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,166.13,69.84,223.7,,,,,,00006-3843-71 - ertapenem 1 g Inj [REEV],,0250,00006-3843-71,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,166.13,4.41,166.13,,,,,,"58160-0842-11 - tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2.5 units-18.5 mcg/0.5 mL IM Susp 0 mL [REEV]",,0250,58160-0842-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,166.13,166.13,1107.72,,,,,,63323-0162-16 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,63323-0162-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,166.13,166.13,1309.77,,,,,,63739-0073-10 - diazepam 5 mg Tab [REEV],,0250,63739-0073-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72156,"Imaging of spinal canal by MRI without contrast, followed by contrast [HCPCS 72156]",1974.7,1481.03,1481.03,561.23,561.23,561.23,,,,,,00143-3142-50 - doxycycline hyclate 100 mg Cap [REEV],,0250,00143-3142-50,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],98.2,73.65,73.65,118.82,41.14,166.13,,,,,,"58160-0823-11 - zoster vaccine, inactivated adjuvanted Pow [REEV]",,0250,58160-0823-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,72193,"Pelvis CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 72193]",1319.8,989.85,989.85,272.21,272.21,1068.37,,,,,,68084-0783-01 - gabapentin 100 mg Cap [REEV],,0250,68084-0783-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73000,"Collar bone x-ray, complete study [HCPCS 73000]",225,168.75,168.75,123.34,123.34,126.58,,,,,,00574-2020-01 - hydrocortisone 100 mg/60 mL Rectal Susp [REEV],,0250,00574-2020-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73020,Shoulder x-ray (single view) [HCPCS 73020],225,168.75,168.75,123.34,98.01,123.34,,,,,,62584-0897-01 - folic acid 1 mg Tab [REEV],,0250,62584-0897-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,123.34,94.25,222.4,,,,,,00409-9093-32 - fentaNYL 0.05 mg/mL Inj Sol [REEV],J3010,0250,00409-9093-32,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],225,168.75,168.75,123.34,27.4,191.25,,,,,,00641-6052-25 - meperidine 25 mg/mL Inj Sol [REEV],J2175,0250,00641-6052-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,123.34,25.73,191.25,,,,,,39822-1201-02 - neomycin-polymyxin B sulfate Top Sol 1 mL [REEV],,0250,39822-1201-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",225,168.75,168.75,123.34,94.25,180,,,,,,00641-0493-25 - phenytoin 50 mg/mL Inj Sol 2 mL [REEV],J1165,0250,00641-0493-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,123.34,24.39,148.78,,,,,,63323-0262-01 - heparin 5000.,J1644,0250,63323-0262-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,123.34,18.85,148.78,,,,,,00406-9050-76 - fentaNYL 50 mcg/hr Transderm ER Film [REEV],,0250,00406-9050-76,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,123.34,33.08,182.07,,,,,,00006-4171-00 - measles/mumps/rubella/varicella virus vaccine SC Inj (PHS) [REEV],,0250,00006-4171-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,166.13,99,166.13,,,,,,51079-0889-20 - pentoxifylline 400 mg ER Tab [REEV],,0250,51079-0889-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,123.34,30.08,220.5,,,,,,00703-7221-04 - ondansetron 4.,J2405,0250,00703-7221-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,123.34,94.25,191.25,,,,,,00009-0856-08 - carboprost 250 mcg/mL Inj Sol [REEV],,0250,00009-0856-08,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73501,Hip x-ray of hip with pelvis (single view) [HCPCS 73501],225,168.75,168.75,123.34,49.24,127.42,,,,,,42858-0304-16 - HYDROmorphone 473.,,0250,42858-0304-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,123.34,57.76,225,,,,,,00904-6571-61 - allopurinol 100 mg Tab [REEV],,0250,00904-6571-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],225,168.75,168.75,123.34,94.25,225,,,,,,00591-0149-87 - sodium ferric gluconate complex 12.5 mg/mL IV Sol (PHS) [REEV],J2916,0250,00591-0149-87,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,123.34,29.4,177.53,,,,,,51079-0928-20 - labetalol 100 mg Tab [REEV],,0250,51079-0928-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,123.34,94.25,214.2,,,,,,00904-5854-61 - ibuprofen 600 mg Tab [REEV],,0250,00904-5854-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,166.13,73.09,246.59,,,,,,66758-0190-13 - potassium chloride 20 mEq ER Tab [REEV],,0250,66758-0190-13,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],225,168.75,168.75,101.93,27.06,225,,,,,,51079-0966-20 - famotidine 20 mg Tab [REEV],,0250,51079-0966-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,123.34,94.25,191.25,,,,,,58468-0090-03 - hylan G-F 20,,0250,58468-0090-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,123.34,69.84,225,,,,,,00378-1902-01 - midodrine 5 mg Tab (PHS) [REEV],,0250,00378-1902-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,123.34,56.37,178.99,,,,,,43547-0369-09 - valsartan 160 mg Tab [REEV],,0250,43547-0369-09,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,123.34,37.7,213.75,,,,,,00904-6627-35 - carbamide peroxide Otic 6.5% Sol [REEV],,0250,00904-6627-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],225,168.75,168.75,101.93,94.25,148.78,,,,,,24338-0102-13 - erythromycin 250 mg Tab [REEV],,0250,24338-0102-13,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",694.6,520.95,520.95,166.13,166.13,526.22,,,,,,00904-5313-46 - Prenatal Multivitamins with Folic Acid 0.8 mg Tab [REEV],,0250,00904-5313-46,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],1046.4,784.8,784.8,350.85,350.85,636.21,,,,,,13533-0636-05 - hepatitis B immune globulin,,0250,13533-0636-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,123.34,90,225,,,,,,00641-6020-10 - morphine 0.5 mg/mL preservative-free Inj Sol [REEV],J2274,0250,00641-6020-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,166.13,31.41,166.13,,,,,,00409-3796-01 - ketorolac 60 mg/2 mL (PHS) [REEV],J1885,0250,00409-3796-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,74022,"Abdominal x-ray, complete study including 2 or more views of abdomen and single view of chest [HCPCS 74022]",377.1,282.83,282.83,166.13,158,229.27,,,,,,60687-0229-01 - loperamide 2 mg Cap [REEV],,0250,60687-0229-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,350.85,180.22,3324.06,,,,,,"63323-0542-01 - heparin 10,000 units/mL Inj Sol [REEV]",J1644,0250,63323-0542-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,561.23,561.23,2500,,,,,,74300-0000-70 - zinc oxide Top 40% Oint [REEV],,0250,74300-0000-70,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",4712.1,3534.08,3534.08,561.23,561.23,2284.78,,,,,,00641-1495-35 - promethazine 25 mg/mL Inj Sol [REEV],J2550,0250,00641-1495-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76010,"Imaging from nose to rectum for foreign body (single view, child) [HCPCS 76010]",225,168.75,168.75,123.34,123.34,123.34,,,,,,68084-0865-01 - carvedilol 12.5 mg Tab [REEV],,0250,68084-0865-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,166.13,110.94,589.78,,,,,,00338-0089-04 - Dextrose 5% with NS IV Sol 1000 mL [REEV],,0250,00338-0089-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,166.13,166.13,421.2,,,,,,00338-0043-04 - Sodium Chloride 0.45% IV Sol 1000 mL [REEV],,0250,00338-0043-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,123.34,62.12,274.64,,,,,,00487-9301-03 - sodium chloride 0.9% Inh Sol 3 mL [REEV],,0250,00487-9301-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,166.13,166.13,529.3,,,,,,00409-4031-01 - mannitol 25% IV Sol 50 mL [REEV],J2150,0250,00409-4031-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,166.13,137.3,401.67,,,,,,00409-2596-03 - midazolam 25 mg/5mL Inj Sol [REEV],J2250,0250,00409-2596-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",653.9,490.43,490.43,166.13,137.3,397.57,,,,,,00409-6651-06 - potassium chloride 2 mEq/mL 10 mL IV Sol [REEV],J3480,0250,00409-6651-06,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,166.13,137.3,529.3,,,,,,00781-3404-95 - ampicillin 1 g Inj [REEV],J0290,0250,00781-3404-95,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76810,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (each additional gestation) [HCPCS 76810]",125.7,94.28,94.28,112.72,112.72,112.72,,,,,,13533-0636-03 - hepatitis B immune globulin IM Sol 0 mL (NEONATAL) [REEV],J1573,0250,13533-0636-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76811,Abdominal ultrasound of pregnant uterus with fetal and maternal evaluation (single or first fetus) [HCPCS 76811],785,588.75,588.75,350.85,350.85,350.85,,,,,,00093-7222-98 - fosinopril 10 mg Tab [REEV],,0250,00093-7222-98,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76815,"Abdominal ultrasound of pregnant uterus limited to fetal position, heart beat, and amniotic fluid volume (1 or more fetuses) [HCPCS 76815]",357.3,267.98,267.98,166.13,166.13,289.17,,,,,,"58160-0812-11 - diphtheria/pertussis,acel/tetanus/polio IM Susp 0 mL [REEV]",,0259,58160-0812-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76816,Abdominal ultrasound of pregnant uterus for re-evaluation of fetus (per fetus) [HCPCS 76816],357.3,267.98,267.98,166.13,166.13,166.13,,,,,,24208-0790-62 - gramicidin/neomycin/polymyxin B Ophth Sol [REEV],,0250,24208-0790-62,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,166.13,92.55,635.38,,,,,,00338-0125-03 - Dextrose 5% in Lactated Ringers IV Sol 500 mL [REEV],,0250,00338-0125-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76819,Fetal heart ultrasound and monitoring without non-stress testing [HCPCS 76819],517.2,387.9,387.9,166.13,137.3,166.13,,,,,,45802-0759-30 - promethazine 25 mg Supp [REEV],,0250,45802-0759-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,166.13,166.13,529.81,,,,,,68084-0524-01 - potassium chloride 10 mEq ER Tab [REEV],,0250,68084-0524-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,166.13,166.13,1065.48,,,,,,45802-0434-01 - clotrimazole Top 1% Crm [REEV],,0250,45802-0434-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",468.7,351.53,351.53,166.13,166.13,311.42,,,,,,00641-1410-31 - digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [REEV],J1160,0250,00641-1410-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76870,Imaging of scrotum by ultrasound [HCPCS 76870],468.7,351.53,351.53,166.13,166.13,309.92,,,,,,68084-0366-01 - digoxin 125 mcg (0.125 mg) Tab [REEV],,0250,68084-0366-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],309.9,232.43,232.43,65.46,22.66,204.92,,,,,,55513-0005-04 - darbepoetin alfa 100 mcg/mL Inj Sol (PHS) [REEV],J0882,0250,55513-0005-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,23.61,23.61,157.86,,,,,,00006-4047-41 - rotavirus vaccine pentavalent oral Susp 2 mL (PHS) [REEV],,0250,00006-4047-41,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],485.7,364.28,364.28,84.74,84.74,462.5,,,,,,00143-9853-75 - amoxicillin-clavulanate 600 mg-42.9 mg/5 mL Oral Liq 75 Ml (bottle) [REEV],,0250,00143-9853-75,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,108.36,108.36,412.85,,,,,,00409-1283-31 - HYDROmorphone 1.,J1170,0250,00409-1283-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,89.59,89.59,349.41,,,,,,64980-0104-01 - potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab [REEV],,0250,64980-0104-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,77072,Imaging for bone age study [HCPCS 77072],452.1,339.08,339.08,166.13,21.71,166.13,,,,,,00187-4302-02 - nitroprusside 25 mg/mL IV Sol [REEV],,0250,00187-4302-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,14.02,8.49,161,,,,,,00603-1508-58 - PHENobarbital 20 mg/5 mL Oral Elix [REEV],,0250,00603-1508-58,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,41.68,41.68,551.29,,,,,,00409-1890-01 - morphine 2 mg/mL preservative-free [REEV],J2270,0250,00409-1890-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,17.5,8.87,355.2,,,,,,51079-0776-20 - hydrochlorothiazide 12.5 mg Cap [REEV],,0250,51079-0776-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,43.35,43.35,182.52,,,,,,68084-0269-01 - hydroxychloroquine 200 mg Tab [REEV],,0250,68084-0269-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,22.2,11.25,148.9,,,,,,63323-0614-01 - hydrALAZINE 20 mg/mL Inj Sol [REEV],J0360,0250,63323-0614-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,78.95,48.41,364.52,,,,,,63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL (PHS) [REEV],,0250,63323-0187-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,13.54,8.3,183.45,,,,,,49281-0510-05 - diphth/haemophilus/pertussis/tetanus/polio - Kit (PHS) [REEV],,0250,49281-0510-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80156,Lab analysis to measure the amount of carbamazepine (total) in blood specimen [HCPCS 80156],233.8,175.35,175.35,24.15,24.15,24.15,,,,,,17478-0404-01 - fluorescein sodium ophthalmic strip [REEV],,0250,17478-0404-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80177,Lab analysis to measure the amount of levetiracetam in blood specimen [HCPCS 80177],186.4,139.8,139.8,21.96,21.96,21.96,,,,,,00386-0001-02 - ethyl chloride Top 100% Spry (PHS) [REEV],,0250,00386-0001-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],99.3,74.48,74.48,21.96,13.12,94.5,,,,,,00409-6653-05 - potassium chloride 40.,J3480,0250,00409-6653-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80201,Lab analysis to measure the amount of topiramate in serum or plasma specimen [HCPCS 80201],131.3,98.48,98.48,16.33,16.33,16.33,,,,,,55566-2800-01 - dinoprostone 10mg Vag Insert [REEV],,0250,55566-2800-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,28.41,14.4,297.7,,,,,,00169-1834-11 - insulin isophane human recombinant 100 units/mL SubQ Inj [REEV],J1815,0250,00169-1834-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,103.01,63.16,518.42,,,,,,00338-0695-04 - Sodium Chloride 0.9% with KCl 40 mEq/l IV Sol 1000 mL [REEV],,0250,00338-0695-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,18.59,9.42,73.71,,,,,,50242-0120-01 - tenecteplase 50 mg IV Inj (PHS) [REEV],J3101,0250,50242-0120-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,19,9.63,285.09,,,,,,70515-0262-10 - digoxin 100 mcg/mL (0.1 mg/mL) Inj Sol (pedi) [REEV],J1160,0250,70515-0262-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,5.25,2.66,76.2,,,,,,00054-0018-20 - predniSONE 20 mg Tab [REEV],,0250,00054-0018-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,0,2.09,3.53,,,,,,00487-5901-99 - racepinephrine 2.25% UD [REEV],,0250,00487-5901-99,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,3.73,1.89,53,,,,,,00409-3578-01 - tobramycin 40 mg/mL Inj Sol [REEV],J3260,0250,00409-3578-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,14.27,6.2,81.6,,,,,,00143-9726-01 - testosterone 2000.,J1071,0250,00143-9726-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,81511,"Lab analysis of four analytes (afp, ue3, hcg [any form], dia) from maternal serum to identify the risk of fetal birth defects [HCPCS 81511]",657.1,492.83,492.83,0,124.73,771.24,,,,,,00270-5164-14 - gadobenate dimeglumine 529 mg/mL IV Sol [REEV],,0255,00270-5164-14,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82010,"Lab analysis to measure the amount of ketone bodies in blood, serum, or plasma specimen [HCPCS 82010]",75.6,56.7,56.7,11.19,8.3,45.2,,,,,,17478-0542-02 - adenosine 3 mg/mL IV Sol [REEV],J0153,0250,17478-0542-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,8.2,5.03,33.1,,,,,,00245-0008-35 - calcitonin 200 intl units/inh Nasal Spry [REEV],,0250,00245-0008-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,9.58,2.31,20.91,,,,,,60505-0759-05 - cefOXitin 1 g Inj [REEV],J0694,0250,60505-0759-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],314.3,235.73,235.73,27.79,14.09,91.91,,,,,,00731-0401-06 - zinc sulfate 220 mg Cap [REEV],,0250,00731-0401-06,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82139,"Lab analysis to measure the amino acid level (6 or more amino acids, each specimen) [HCPCS 82139]",620.8,465.6,465.6,27.96,27.96,27.96,,,,,,00085-0566-05 - betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [REEV],J0702,0250,00085-0566-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],137.9,103.43,103.43,24.15,14.81,137.9,,,,,,55390-0475-10 - ketamine 50 mg/mL Inj Sol dose [REEV],,0250,55390-0475-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,10.74,5.44,96,,,,,,10019-0641-34 - desflurane 100% Inh Liq 240 mL [REEV],,0250,10019-0641-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82247,Lab analysis to measure the total bilirubin level [HCPCS 82247],118.1,88.58,88.58,8.32,4.22,50.4,,,,,,63323-0311-10 - calcium gluconate 100 mg/mL Inj Sol [REEV],J0610,0250,63323-0311-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],118.1,88.58,88.58,8.32,4.22,71.8,,,,,,68084-0676-01 - metoclopramide 10 mg Tab [REEV],,0250,68084-0676-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],30.9,23.18,23.18,0,12.94,18.79,,,,,,60505-2656-01 - hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab [REEV],,0250,60505-2656-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,26.39,16.18,45.86,,,,,,51079-0451-20 - amLODIPine 5 mg Tab [REEV],,0250,51079-0451-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,49.08,30.08,290.1,,,,,,00517-0374-05 - methylene blue 5 mg/mL [REEV],,0250,00517-0374-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82379,Lab analysis to measure the carnitine level [HCPCS 82379],51.7,38.78,38.78,27.96,27.96,27.96,,,,,,59762-0541-01 - glipiZIDE 5 mg ER Tab [REEV],,0250,59762-0541-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82530,Lab analysis to measure the amount of free cortisol (hormone) [HCPCS 82530],237.1,177.83,177.83,27.7,16.71,233.8,,,,,,00641-0477-25 - PHENobarbital 130 mg/mL Inj Sol [REEV],J2560,0250,00641-0477-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82540,Lab analysis to measure the amount of creatine in urine or serum specimen [HCPCS 82540],13.4,10.05,10.05,7.7,7.7,7.7,,,,,,00338-0017-48 - Dextrose 5% in Water IV Sol 100 mL [REEV],,0250,00338-0017-48,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,10.79,5.81,65.1,,,,,,00409-1631-10 - calcium chloride 100 mg/mL Inj Sol [REEV],J3490,0250,00409-1631-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,19.7,11.55,98.31,,,,,,08290-3065-46 - sodium chloride 0.9% Inj Sol 10 mL [REEV],,0250,08290-3065-46,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,13.58,5.2,40.9,,,,,,63323-0284-20 - vancomycin 1 g IV Inj [REEV],J3370,0250,63323-0284-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,8.59,4.35,81.23,,,,,,10122-0313-10 - niCARdipine 20 mg/200 mL-NaCl 0.86% IV Sol [REEV],,0250,10122-0313-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82575,Lab analysis to measure the creatinine clearance in urine and blood specimens to test for kidney function [HCPCS 82575],131.3,98.48,98.48,15.68,9.62,15.68,,,,,,24987-0378-10 - cefTAZidime 1 g Inj [REEV],J0713,0250,24987-0378-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,25,12.67,98.39,,,,,,16714-0296-01 - amoxicillin-clavulanate 500 mg-125 mg Tab [REEV],,0250,16714-0296-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82626,Lab analysis to measure the dehydroepiandrosterone (DHEA) hormone level [HCPCS 82626],275.7,206.78,206.78,41.89,41.89,41.89,,,,,,00641-6057-25 - midazolam 1 mg/mL Inj Sol [REEV],J2250,0250,00641-6057-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,63.82,32.34,465.3,,,,,,67457-0228-10 - rocuronium 10 mg/mL IV Sol [REEV],,0250,67457-0228-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],480.7,360.53,360.53,46.32,28.4,180.6,,,,,,00641-2555-45 - phenytoin 50 mg/mL 5 mL Inj Sol [REEV],J1165,0250,00641-2555-45,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82677,Lab analysis to measure the estriol (hormone) level [HCPCS 82677],167.6,125.7,125.7,40.09,20.31,40.09,,,,,,"58160-0964-12 - rabies vaccine, purified chick embryo cell 2.5 IntlUnit Powder-Inj",,0250,58160-0964-12,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,22.59,11.45,112.4,,,,,,00054-0017-20 - predniSONE 10 mg Tab [REEV],,0250,00054-0017-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,24.37,14.94,192.28,,,,,,00338-0703-48 - potassium chloride 40 mEq/100 mL IV Sol [REEV],,0250,00338-0703-48,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82784,Lab analysis to measure the amount of gammaglobulin (immune system protein) [HCPCS 82784],100.4,75.3,75.3,15.42,15.42,15.42,,,,,,50383-0618-04 - loperamide 1 mg/5 mL Oral Liq (bottle) [REEV],,0250,50383-0618-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82785,Lab analysis to measure the IgE (immune system protein) level [HCPCS 82785],135.7,101.78,101.78,27.29,16.51,56.85,,,,,,00591-0343-01 - verapamil 80 mg Tab [REEV],,0250,00591-0343-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82803,Lab analysis to measure the amount of blood gases [HCPCS 82803],293.3,219.98,219.98,40.03,26.5,223.7,,,,,,00904-6407-61 - bisacodyl 5 mg Oral EC Tab [REEV],,0250,00904-6407-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,6.51,3.99,48.28,,,,,,63323-0106-05 - magnesium sulfate 2 g/50 mL-sterile water [REEV],,0250,63323-0106-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,21.33,10.81,66.12,,,,,,46287-0006-60 - sodium polystyrene sulfonate 15 g/60 mL Sus UD [REEV],,0250,46287-0006-60,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82952,Lab analysis to measure blood glucose (sugar) tolerance (each additional specimens beyond 3 specimens) [HCPCS 82952],38.7,29.03,29.03,6.5,3.98,38.7,,,,,,00409-1323-05 - lidocaine 2% preservative-free 5 mL [REEV],J2001,0250,00409-1323-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,0,2.66,8.7,,,,,,63323-0369-20 - ampicillin-sulbactam 2 g-1 g Inj [REEV],J0295,0250,63323-0369-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,82977,Lab analysis to measure the glutamyltransferase (liver enzyme) level [HCPCS 82977],65.1,48.83,48.83,11.93,11.93,52.08,,,,,,00006-4827-00 - varicella virus vaccine SubQ Inj [REEV],,0250,00006-4827-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,30.79,16.1,220.5,,,,,,00143-9746-10 - terbutaline 1 mg/mL Inj Sol [REEV],J7681,0250,00143-9746-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",399.1,299.33,299.33,30.7,18.83,178.6,,,,,,00409-2344-02 - DOBUTamine 12.5 mg/mL IV Sol [REEV],J1250,0250,00409-2344-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83003,Lab analysis to measure the human growth hormone level in amniotic fluid specimen [HCPCS 83003],135.7,101.78,101.78,27.64,27.64,56.85,,,,,,00002-8031-01 - glucagon 1. mg Powder-Inj,,0250,00002-8031-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,111.66,56.58,188.42,,,,,,08290-3065-45 - sodium chloride 0.9% Inj Sol 5 mL [REEV],,0250,08290-3065-45,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83021,Lab analysis to identify and measure the amount of hemoglobin in blood specimen by chromatography [HCPCS 83021],248.2,186.15,186.15,29.95,29.95,29.95,,,,,,00187-0658-20 - diazepam 10 mg rectal kit [REEV],J3360,0250,00187-0658-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,13.3,8.16,104.31,,,,,,24208-0910-55 - erythromycin Ophth 0.5% Oint [REEV],,0250,24208-0910-55,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,19.11,11.58,453.2,,,,,,00338-5197-41 - famotidine 20 mg/50 mL IV Sol [REEV],,0250,00338-5197-41,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83525,Lab analysis to measure the amount of total insulin [HCPCS 83525],147.8,110.85,110.85,18.95,18.95,89.86,,,,,,00409-4910-34 - atropine 0.1 mg/mL 5 mL Inj Sol [REEV],J0461,0250,00409-4910-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,10.72,5.43,33.59,,,,,,42023-0104-01 - tuberculin purified protein derivative 5 TU/0.1 mL ID 1 mL Sol [REEV],,0250,42023-0104-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,14.48,7.34,38.68,,,,,,00409-6629-02 - succinylcholine 20 mg/mL Inj Sol [REEV],J0330,0250,00409-6629-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,19.18,9.72,190.22,,,,,,00003-0293-05 - triamcinolone acetonide 40 mg/mL 1 mL Inj Susp [REEV],J3301,0250,00003-0293-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,10.01,5.07,94.54,,,,,,00338-0089-03 - Dextrose 5% with NS IV Sol 500 mL [REEV],,0250,00338-0089-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83655,Lab analysis to measure the lead level in blood specimen [HCPCS 83655],123.5,92.63,92.63,20.07,12.31,122.26,,,,,,00009-0280-03 - methylPREDNISolone 40. mg Susp,,0250,00009-0280-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,11.42,5,105.9,,,,,,49281-0545-05 - haemophilus b conjugate (PRP-T) vaccine IM Inj (PHSj [REEV],,0250,49281-0545-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83727,Lab analysis to measure the luteinizing releasing factor (reproductive hormone) level in blood specimen [HCPCS 83727],402.5,301.88,301.88,28.5,28.5,28.5,,,,,,59528-0331-02 - calcium acetate 667 mg Tab [REEV],,0250,59528-0331-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,11.11,5.63,72.8,,,,,,00487-9904-25 - albuterol 0.042% Inh Sol 3 mL [REEV],J7613,0250,00487-9904-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83789,Lab analysis by mass spectrometry [HCPCS 83789],654.9,491.18,491.18,39.97,39.97,39.97,,,,,,00409-4921-34 - EPINEPHrine 0.1 mg/mL Inj Sol [REEV],J0171,0250,00409-4921-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,65.09,32.98,268.8,,,,,,00904-0523-61 - ascorbic acid 500 mg Tab [REEV],,0250,00904-0523-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83921,Lab analysis to measure the organic acid level in urine specimen [HCPCS 83921],393.7,295.28,295.28,35.16,35.16,35.16,,,,,,00338-0049-31 - Sodium Chloride 0.9% IV Sol 50 mL [REEV],,0250,00338-0049-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,68.44,41.96,133.85,,,,,,00781-1962-60 - clarithromycin 500 mg Tab [REEV],,0250,00781-1962-60,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84030,"Lab analysis to measure the phenylalanine, PKU (amino acid) level in blood specimen [HCPCS 84030]",102.6,76.95,76.95,9.11,4.62,77.09,,,,,,00904-6503-61 - celecoxib 200 mg Cap [REEV],,0250,00904-6503-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,7.85,4.75,40.9,,,,,,00641-6008-10 - bumetanide 0.25 mg/mL Inj Sol [REEV],S0171,0250,00641-6008-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,7.89,7.89,28.7,,,,,,00310-0950-36 - goserelin 3.6 mg,,0250,00310-0950-36,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84134,Lab analysis to measure the prealbumin (protein) level in urine specimen [HCPCS 84134],239.3,179.48,179.48,24.19,24.19,158.23,,,,,,63739-0499-10 - LORazepam 0.5 mg Tab [REEV],,0250,63739-0499-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],144.5,108.38,108.38,34.58,18.12,87.86,,,,,,17478-0420-20 - labetalol 5 mg/mL IV Sol [REEV],J3490,0250,17478-0420-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84145,Lab analysis to measure the procalcitonin (hormone) level in serum or plasma specimen [HCPCS 84145],398.1,298.58,298.58,45.73,27.66,265.89,,,,,,00168-0015-31 - hydrocortisone Top 1% Crm [REEV],,0250,00168-0015-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,32.13,19.44,112.66,,,,,,50268-0525-15 - meloxicam 7.5 mg Tab [REEV],,0250,50268-0525-15,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,30.48,18.45,315.4,,,,,,00270-1315-30 - iopamidol 61% Inj Sol 50 mL [REEV],,0255,00270-1315-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,6.09,3.73,46.16,,,,,,00517-0780-10 - etomidate 2 mg/mL IV Sol [REEV],J3490,0250,00517-0780-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84270,Lab analysis to measure the sex hormone binding globulin (protein) level in serum specimen [HCPCS 84270],240.4,180.3,180.3,36.02,22.08,180.6,,,,,,00009-0775-26 - clindamycin 150 mg/mL IV Sol [REEV],J3490,0250,00009-0775-26,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,42.79,25.9,240.4,,,,,,00052-0450-15 - rocuronium 10 mg/mL IV Sol dose [REEV],,0250,00052-0450-15,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],61.8,46.35,46.35,11.39,11.39,37.57,,,,,,00904-5858-61 - ALPRAZolam 0.25 mg Tab [REEV],,0250,00904-5858-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,14.96,7.58,134.6,,,,,,00228-2497-10 - NIFEdipine 10 mg Cap [REEV],,0250,00228-2497-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,27.85,14.11,134.34,,,,,,00338-1148-03 - Amino Acids 5% with 20% Dextrose and Electrolytes (Clinimix E Sulfite-Free) IV Sol 1000 mL [REEV],,0250,00338-1148-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,7.1,4.35,39.58,,,,,,60505-0834-04 - cefepime 1 g Inj [REEV],J0692,0250,60505-0834-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",65.1,48.83,48.83,7.26,5.38,38.07,,,,,,58160-0825-11 - hepatitis A pediatric vaccine 720 units/0.5 mL PF IM Susp (PHS) [REEV],,0250,58160-0825-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84479,Lab analysis to evaluate thyroid hormone in serum specimen [HCPCS 84479],61.8,46.35,46.35,10.72,7.26,25.87,,,,,,51079-0745-20 - diltiazem 30 mg Tab [REEV],,0250,51079-0745-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,23.51,14.41,153.94,,,,,,00713-0118-12 - acetaminophen 120 mg Supp [REEV],,0250,00713-0118-12,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",233.8,175.35,175.35,28.08,17.22,200.91,,,,,,00088-2220-33 - insulin glargine 100 units/mL SubQ Sol [REEV],J1815,0250,00088-2220-33,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,20.68,9.87,141.2,,,,,,00054-3500-49 - lidocaine oral 2% Sol 100 mL bottle [REEV],,0250,00054-3500-49,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,10.48,4.02,32.1,,,,,,00904-7914-51 - ibuprofen 200 mg Tab [REEV],,0250,00904-7914-51,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,7.49,4.54,50.4,,,,,,63323-0165-30 - dexamethasone 4 mg/mL 30 mL Inj Sol [REEV],J1100,0250,63323-0165-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,34.5,17.05,191.3,,,,,,00904-5306-61 - diphenhydrAMINE 25 mg Cap [REEV],,0250,00904-5306-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,24.95,12.64,85.85,,,,,,50458-0578-30 - rivaroxaban 15 mg Tab [REEV],,0250,50458-0578-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,12.46,7.65,55.26,,,,,,63323-0044-01 - cyanocobalamin 1000 mcg/mL Inj Sol [REEV],J3420,0250,63323-0044-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],44.1,33.08,33.08,3.25,2.41,10,,,,,,00781-1943-82 - amoxicillin-clavulanate 1000 mg-62.5 mg ER Tab [REEV],,0250,00781-1943-82,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],12.2,9.15,9.15,3.25,2.41,10,,,,,,00338-0023-04 - Dextrose 10% in Water IV Sol 1000 mL [REEV],,0250,00338-0023-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,12.87,6,88.2,,,,,,68084-0491-01 - meclizine 25 mg Tab [REEV],,0250,68084-0491-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,10.72,5.43,37.5,,,,,,00409-6637-34 - sodium bicarbonate 8.4% IV Sol 50 mL [REEV],,0250,00409-6637-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85041,Lab analysis to measure red blood cell count (automated test) [HCPCS 85041],341.8,256.35,256.35,5.01,5.01,5.01,,,,,,00536-4406-01 - pyridoxine 25 mg Tab [REEV],,0250,00536-4406-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85045,Lab analysis to measure red blood count (automated test) [HCPCS 85045],100.4,75.3,75.3,6.62,6.62,61.04,,,,,,00005-1971-02 - pneumococcal 13-valent conjugate vaccine - Sus UD (PHS) [REEV],,0250,00005-1971-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85060,Lab analysis to interpret a blood smear by physician with written report [HCPCS 85060],78.4,58.8,58.8,24.12,24.12,32.82,,,,,,00904-5789-61 - acyclovir 200 mg Cap [REEV],,0250,00904-5789-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,16.87,8.55,182.7,,,,,,51293-0810-01 - phenazopyridine 100 mg Tab [REEV],,0250,51293-0810-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,7.11,3.6,69.6,,,,,,61958-1003-01 - ranolazine 500 mg oral ER Tab [REEV],,0250,61958-1003-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,7.08,3.56,42,,,,,,43825-0102-01 - acetaminophen 10 mg/mL [REEV],J0131,0250,43825-0102-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,4.48,2.7,54.33,,,,,,63323-0106-10 - magnesium sulfate 40 g/1000 mL-sterile water [REEV],,0250,63323-0106-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,9.96,6.03,69.6,,,,,,00591-3214-72 - fentaNYL 100 mcg/hr Transderm ER Film [REEV],,0250,00591-3214-72,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86003,Lab analysis to identify antibody IgE to allergic substance (each crude allergen extract) [HCPCS 86003],763,572.25,572.25,8.65,8.65,8.65,,,,,,68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [REEV],,0250,68094-0171-62,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,20.04,12.29,258.33,,,,,,61748-0012-09 - pyrazinamide 500 mg Tab [REEV],,0250,61748-0012-09,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86039,Lab analysis to screen for autoimmune disorders by titer [HCPCS 86039],91.6,68.7,68.7,18.5,18.5,73.28,,,,,,68084-0461-21 - zidovudine 100 mg Cap [REEV],,0250,68084-0461-21,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86060,Lab analysis to identify strep throat antibody [HCPCS 86060],48.6,36.45,36.45,12.1,7.42,20.33,,,,,,00009-0047-22 - methylPREDNISolone 125 mg preservative-free Pow [REEV],J2930,0250,00009-0047-22,29.07,21.8025,21.8025
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,8.59,5.26,76.2,,,,,,00409-1443-04 - norEPINEPHrine 1 mg/mL IV Sol [REEV],,0250,00409-1443-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86141,Lab analysis to measure the amount of C-reactive protein in serum by high sensitivity assay to identify infection or inflammation [HCPCS 86141],155.5,116.63,116.63,22.11,22.11,65.16,,,,,,00409-1778-05 - metoprolol 1 mg/mL Inj Sol [REEV],J3490,0250,00409-1778-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,0,12.2,112.96,,,,,,00093-4175-73 - cephalexin 125 mg/5 mL Oral Liq (bottle) [REEV],,0250,00093-4175-73,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,29.72,18.22,199.4,,,,,,45802-0112-22 - mupirocin Top 2% Oint [REEV],,0250,45802-0112-22,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,19.98,12.25,187.04,,,,,,57664-0185-31 - codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 118 mL [REEV],,0250,57664-0185-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86308,Lab analysis to screen for mononucleosis (mono) [HCPCS 86308],53,39.75,39.75,8.59,5.26,30.95,,,,,,"00574-2008-15 - nystatin Top 100,000 units/g Pwdr [REEV]",,0250,00574-2008-15,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86336,Lab analysis to measure the amount of reproductive organ horomone (inhibin A) [HCPCS 86336],283.4,212.55,212.55,25.85,13.1,25.85,,,,,,68084-0098-01 - atorvastatin 20 mg Tab [REEV],,0250,68084-0098-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,24.12,14.79,121.3,,,,,,"58160-0810-11 - diphtheria/tetanus/pertussis, acel (DTaP) 25 units-10 units-58 mcg/0.5 mL IM Susp 0 mL (PHS) [REEV]",,0250,58160-0810-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,9.4,5.76,186.4,,,,,,00591-0900-30 - glipiZIDE 2.5 mg ER Tab [REEV],,0250,00591-0900-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,7.08,4.34,61.8,,,,,,68084-0347-01 - losartan 50 mg Tab [REEV],,0250,68084-0347-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86593,Lab analysis to identify syphilis for monitoring or re-infection of the disease [HCPCS 86593],30.9,23.18,23.18,7.3,7.3,18.79,,,,,,00409-7338-01 - cefTRIAXone 500 mg Inj [REEV],J0696,0250,00409-7338-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86617,Lab analysis to identify antibodies to Borrelia burgdorferi (Lyme disease bacteria) with confirmation test [HCPCS 86617],147.8,110.85,110.85,25.68,25.68,61.91,,,,,,00338-0013-04 - sterile water Inj 1000 mL Sol [REEV],,0250,00338-0013-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86695,"Lab analysis to identify antibodies to Herpes simplex virus, type 1 [HCPCS 86695]",194.1,145.58,145.58,21.87,13.41,58.37,,,,,,00169-1837-11 - insulin isophane-insulin regular human recombinant 70 units-30 units/mL SubQ Inj 10 mL [REEV],J1815,0250,00169-1837-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86696,"Lab analysis to identify antibodies to Herpes simplex virus, type 2 [HCPCS 86696]",413.5,310.13,310.13,32.08,19.67,254.75,,,,,,59762-4537-01 - medroxyPROGESTERone 150 mg/mL IM Susp [REEV],J1050,0250,59762-4537-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,22.72,11.52,121.3,,,,,,00409-4900-34 - sodium bicarbonate 8.4% IV Sol 10 mL [REEV],,0250,00409-4900-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86765,Lab analysis to identify antibodies to Rubeola (measles virus) [HCPCS 86765],169.8,127.35,127.35,21.36,10.82,53.63,,,,,,60687-0195-01 - diltiazem 120 mg/24 hours ERCap [REEV],,0250,60687-0195-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,57.72,16.62,74.01,,,,,,68462-0352-01 - hydrOXYzine hydrochloride 10 mg Tab [REEV],,0250,68462-0352-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86777,Lab analysis to identify antibodies to Toxoplasma (parasite) [HCPCS 86777],134.5,100.88,100.88,23.85,23.85,23.85,,,,,,76439-0307-10 - hyoscyamine 0.125 mg Dis Tab [REEV],,0250,76439-0307-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86780,Lab analysis to identify antibodies to Treponema pallidum [HCPCS 86780],311,233.25,233.25,21.95,21.95,75.82,,,,,,00338-0017-02 - Dextrose 5% in Water IV Sol 250 mL [REEV],,0250,00338-0017-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86787,Lab analysis to identify antibodies to varicella-zoster virus (chicken pox) [HCPCS 86787],148.9,111.68,111.68,17.65,10.82,90.53,,,,,,00517-4605-25 - glycopyrrolate 0.2 mg/mL Inj Sol [REEV],J3490,0250,00517-4605-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,23.66,11.99,222.7,,,,,,00270-1315-35 - iopamidol 61% Inj Sol 100 mL [REEV],,0255,00270-1315-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,10.01,6.74,92.02,,,,,,51991-0144-17 - methylergonovine 0.2 mg/mL Inj Sol [REEV],J2210,0250,51991-0144-17,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86870,Lab blood analysis to identify antibodies to red blood cells [HCPCS 86870],201.9,151.43,151.43,9.61,9.61,182.51,,,,,,43386-0160-06 - misoprostol 100 mcg Tab [REEV],,0250,43386-0160-06,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86886,Lab blood analysis to measure the strength of antibody to red blood cell [HCPCS 86886],155.5,116.63,116.63,8.59,5.26,8.59,,,,,,00904-6084-61 - citalopram 10 mg Tab [REEV],,0250,00904-6084-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,11.93,11.93,144.95,,,,,,59762-0401-01 - sucralfate 1 g Tab [REEV],,0250,59762-0401-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,17.11,9.2,112.32,,,,,,00093-1172-01 - Penicillin V Potassium 250 mg Tab [REEV],,0250,00093-1172-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],54.4,40.8,40.8,15.66,9.6,22.79,,,,,,00338-0054-03 - Sodium Chloride 3% IV Sol 500 mL [REEV],,0250,00338-0054-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87046,Lab analysis of stool culture to identify bacteria and additional pathogens [HCPCS 87046],54.4,40.8,40.8,15.66,7.93,15.66,,,,,,63323-0649-07 - levothyroxine 100 mcg (0.1 mg) Pow [REEV],,0250,63323-0649-07,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,14.29,7.24,496.86,,,,,,63323-0064-10 - magnesium sulfate 50% Inj Sol 10 mL [REEV],J3475,0250,63323-0064-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,15.69,9.38,86.39,,,,,,"63323-0461-57 - bupivacaine 0.25%-EPINEPHrine 1:200,000 Inj Sol 50 mL [REEV]",,0250,63323-0461-57,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,13.39,6.79,100.4,,,,,,10019-0553-01 - scopolamine 1.5 mg Transderm ER Film [REEV],,0250,10019-0553-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,10.99,5.57,65.1,,,,,,00536-3222-01 - acetaminophen 325. mg Tab,,0250,00536-3222-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,13.37,2.84,108.1,,,,,,00008-4990-20 - tigecycline 50. mg Powder-Inj,,0250,00008-4990-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,13.41,6.8,52.43,,,,,,00781-3407-95 - ampicillin 500 mg Inj [REEV],J0290,0250,00781-3407-95,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87106,Lab analysis of fungal culture to identify yeast [HCPCS 87106],152.2,114.15,114.15,17.11,8.67,29.64,,,,,,45963-0556-11 - gabapentin 300 mg Cap [REEV],,0250,45963-0556-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],56.8,42.6,42.6,14.76,8.9,23.8,,,,,,"49281-0860-10 - poliovirus vaccine, inactivated SubQ Susp 5 mL (PHS) [REEV]",,0250,49281-0860-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,14.34,7.27,172,,,,,,66993-0021-27 - levalbuterol 0.31 mg/3 mL Inh Sol [REEV],,0250,66993-0021-27,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,7.08,4.29,39.3,,,,,,59762-4900-03 - sertraline 50 mg Tab [REEV],,0250,59762-4900-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],56.8,42.6,42.6,29.8,12.41,29.8,,,,,,66689-0202-04 - charcoal 25 g Oral Susp 120 mL [REEV],,0250,66689-0202-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87210,"Lab analysis of wet mount to identify bacteria, fungi, or parasites [HCPCS 87210]",32.1,24.08,24.08,9.64,9.64,9.64,,,,,,00228-2127-10 - cloNIDine 0.1 mg Tab,,0250,00228-2127-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87254,Lab analysis of isolated viruses by centrifuge enhanced method [HCPCS 87254],419,314.25,314.25,32.43,19.88,254.75,,,,,,18657-0117-04 - hyaluronidase 150 units/mL Inj Sol [REEV],J3470,0250,18657-0117-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87255,Lab analysis of isolated viruses by non-immunologic method [HCPCS 87255],326.4,244.8,244.8,56.12,56.12,198.45,,,,,,00338-0803-04 - Dextrose 5% with NS and KCl 20 mEq/l IV Sol 1000 mL [REEV],,0250,00338-0803-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87328,Lab analysis by immunoassay (ELISA) to identify cryptosporidium (parasite) [HCPCS 87328],136.8,102.6,102.6,22.91,11.61,22.91,,,,,,00338-0017-04 - Dextrose 5% in Water IV Sol 1000 mL [REEV],,0250,00338-0017-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87329,Lab analysis by immunoassay (ELISA) to identify giardia (intestinal parasite) [HCPCS 87329],186.4,139.8,139.8,19.86,19.86,78.1,,,,,,51079-0952-20 - enalapril 10 mg Tab [REEV],,0250,51079-0952-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87339,Lab analysis by immunoassay (ELISA) to identify helicobacter pylori (GI tract bacteria) [HCPCS 87339],217.3,162.98,162.98,0,13,16,,,,,,60432-0608-04 - promethazine 147.5 Syrup,,0250,60432-0608-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,23.43,8.17,155.5,,,,,,00054-0007-25 - calcitriol 0.25 mcg Oral Cap [REEV],,0250,00054-0007-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,23.06,11.68,116.85,,,,,,55566-5030-01 - desmopressin 4 mcg/mL IV Sol [REEV],J2597,0250,55566-5030-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87425,Lab analysis by immunoassay (ELISA) to identify Rotavirus [HCPCS 87425],207.3,155.48,155.48,19.86,19.86,19.86,,,,,,00270-1316-01 - iopamidol 76% Inj Sol 50 mL [REEV],,0250,00270-1316-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,61.97,37.79,110.3,,,,,,00641-6142-25 - phenylephrine 10 mg/mL Inj Sol [REEV],J2370,0250,00641-6142-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],211.7,158.78,158.78,19.86,11.89,22.79,,,,,,00904-6506-61 - memantine 10 mg Tab [REEV],,0250,00904-6506-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,27.87,14.12,74.6,,,,,,00904-0539-61 - Therapeutic Multiple Vitamins Tab [REEV],,0250,00904-0539-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",342.7,257.03,257.03,19.86,11.91,22.84,,,,,,00121-1744-10 - guaiFENesin 100 mg/5 mL Oral Liq SF [REEV],,0250,00121-1744-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,58.16,29.48,155.5,,,,,,00574-7050-50 - bisacodyl 10 mg Supp [REEV],,0250,00574-7050-50,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],282.3,211.73,211.73,61.78,31.31,118.27,,,,,,00168-0021-31 - bacitracin-polymyxin B Top Oint [REEV],,0250,00168-0021-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,58.16,29.48,155.5,,,,,,00904-6408-61 - donepezil 5 mg Tab [REEV],,0250,00904-6408-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,21.42,4.29,35.67,,,,,,63323-0013-02 - thiamine 100 mg/mL Inj Sol [REEV],J3411,0250,63323-0013-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,116.37,58.97,116.37,,,,,,10481-0111-08 - iodine-potassium iodide 5%-10% oral Sol 8 mL [REEV],,0250,10481-0111-08,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,00597-0053-45 - glucagon 1 mg Inj [REEV],J1610,0250,00597-0053-45,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,58.16,29.48,105,,,,,,00121-0504-16 - acetaminophen-codeine 120 mg-12 mg/5 mL,,0250,00121-0504-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87798,Lab analysis by nucleic acid (DNA or RNA) to identify organism by amplified probe technique [HCPCS 87798],638.4,478.8,478.8,0,267.52,426.39,,,,,,36000-0009-24 - ciprofloxacin 400 mg/200 mL IV Sol [REEV],J0744,0250,36000-0009-24,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,72.38,40.24,406.9,,,,,,63739-0349-10 - lisinopril 10 mg Tab [REEV],,0250,63739-0349-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,88108,Lab examination of specimen by the conentration technique to diagnose disease [HCPCS 88108],33.1,24.83,24.83,38.12,13.86,38.85,,,,,,00006-4109-09 - human papillomavirus vaccine IM Susp 0 mL [REEV],,0250,00006-4109-09,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,21.42,4.29,27.04,,,,,,51079-0072-20 - furosemide 20 mg Tab [REEV],,0250,51079-0072-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,0,13.86,24.19,,,,,,00527-1311-01 - terbutaline 5 mg Tab [REEV],,0250,00527-1311-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,88304,Pathology lab analysis of tissue with microscope (moderately low complexity) [HCPCS 88304],33.1,24.83,24.83,0,25.06,25.06,,,,,,00093-4148-64 - levalbuterol 1.25 mg/3 mL Inh Sol [REEV],J7614,0250,00093-4148-64,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,32.95,20.12,77.89,,,,,,"00409-3178-01 - EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20 mL (PHS) [REEV]",,0250,00409-3178-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,89055,Lab analysis to measure the amount of white blood cells in stool specimen [HCPCS 89055],65.1,48.83,48.83,7.08,3.59,27.28,,,,,,00409-7811-24 - metroNIDAZOLE 500 mg/100 mL IV Sol [REEV],J3490,0250,00409-7811-24,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,92950,Heart and lungs restart (attempt) [HCPCS 92950],695.8,521.85,521.85,171,71.63,200.7,,,,,,00338-1134-03 - Amino Acids 4.25% with 10% Dextrose (Clinimix Sulfite-Free) IV Sol 1000 mL [REEV],,0250,00338-1134-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,6.15,6.15,4344.87,,,,,,00378-0415-01 - atropine-diphenoxylate 0.025 mg-2.5 mg Tab [REEV],,0250,00378-0415-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,160.82,39.27,311.42,,,,,,67457-0153-18 - amiodarone 50 mg/mL IV Sol [REEV],J0282,0250,67457-0153-18,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,93925,Leg ultrasound of arteries and arterial grafts of both legs (complete study) [HCPCS 93925],1018.8,764.1,764.1,350.85,350.85,673.66,,,,,,00023-0312-04 - ocular lubricant Oint [REEV],,0250,00023-0312-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,93926,Arteries and arterial grafts ultrasound of one leg (limited study) [HCPCS 93926],713.4,535.05,535.05,166.13,166.13,606.39,,,,,,00121-0504-04 - acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 118 mL [REEV],,0250,00121-0504-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",1427.8,1070.85,1070.85,350.85,350.85,944.09,,,,,,00338-0691-04 - Sodium Chloride 0.9% with KCl 20 mEq/l IV Sol 1000 mL [REEV],,0250,00338-0691-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,166.13,166.13,1092.27,,,,,,63323-0285-65 - ropivacaine 0.2% Inj Sol 100 mL [REEV],J2795,0250,63323-0285-65,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,94010,Total and timed exhaled air capacity measurement and graphic recording [HCPCS 94010],261.4,196.05,196.05,21.05,21.05,222.19,,,,,,00496-0882-15 - lidocaine Top 4% Crm (PHS) [REEV],,0250,00496-0882-15,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,94060,Amount and speed of breathed air measurement and graphic recording before and after medication administration [HCPCS 94060],308.7,231.53,231.53,35.66,20,362.32,,,,,,00641-0376-25 - diphenhydrAMINE 50.,J1200,0250,00641-0376-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,16.49,16.49,98.36,,,,,,00185-0129-01 - bumetanide 1 mg Tab [REEV],,0250,00185-0129-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,19.15,19.15,448.97,,,,,,63739-0354-10 - magnesium oxide 400 mg Tab [REEV],,0250,63739-0354-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,94668,Manual chest wall manipulation for improved lung function (subsequent evaluation) [HCPCS 94668],83.8,62.85,62.85,31.24,31.24,31.24,,,,,,00406-9025-76 - fentaNYL 25 mcg/hr Transderm ER Film [REEV],,0250,00406-9025-76,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,28.6,28.6,1161.38,,,,,,10223-0201-03 - benzocaine/butamben/tetracaine Top Aer [REEV],,0250,10223-0201-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,16.26,16.26,2475.42,,,,,,60687-0379-01 - benztropine 2 mg Tab [REEV],,0250,60687-0379-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,68.61,68.61,524.17,,,,,,"58160-0811-52 - diphtheria/hepB/pertussis,acel/polio/tetanus IM Susp 0 mL (PHS) [REEV]",,0250,58160-0811-52,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,20.72,20.72,3197.1,,,,,,00574-0107-70 - clotrimazole 10 mg Loz [REEV],,0250,00574-0107-70,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,0,34.19,143.78,,,,,,00713-0135-12 - prochlorperazine 25 mg Supp [REEV],,0250,00713-0135-12,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96368,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (concurrent with another infusion) [HCPCS 96368]",92.7,69.53,69.53,0,38.81,108.8,,,,,,52268-0100-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [REEV],,0250,52268-0100-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,12.56,4.51,1156.79,,,,,,69387-0119-01 - benzonatate 100 mg Cap [REEV],,0250,69387-0119-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,29.4,29.4,2785.69,,,,,,00487-9501-60 - albuterol 0.083% Inh Sol 3 mL [REEV],J7613,0250,00487-9501-60,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,12.56,12.56,48.28,,,,,,55566-1501-01 - chorionic gonadotropin (HCG) 10000. IntlUnit Powder-Inj,,0250,55566-1501-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,12.56,10.24,44.01,,,,,,70860-0776-02 - ondansetron 2 mg/mL Inj Sol [REEV],J2405,0250,70860-0776-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,96900,Ultraviolet light application to skin [HCPCS 96900],92.2,69.15,69.15,23.1,23.1,23.1,,,,,,27437-0050-57 - methylergonovine 0.2 mg Tab [REEV],,0250,27437-0050-57,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,13.42,13.42,41.31,,,,,,25021-0402-66 - heparin 5000 units/mL Inj Sol [REEV],J1644,0250,25021-0402-66,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,40.84,40.84,136.8,,,,,,00187-1704-05 - phytonadione 5 mg Tab [REEV],,0250,00187-1704-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,40.84,40.84,143.78,,,,,,00338-0085-04 - Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [REEV],,0250,00338-0085-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],101.5,76.13,76.13,37.78,37.78,80.08,,,,,,55111-0683-01 - ibuprofen 600. mg Tab,,0250,55111-0683-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,38.48,23.51,98.36,,,,,,00121-0544-10 - docusate sodium 150 mg/15 mL Oral Liq [REEV],,0250,00121-0544-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,140.59,140.59,428.4,,,,,,"49281-0790-51 - typhoid vaccine, inactivated IM Sol 0 mL (PHS) [REEV]",,0250,49281-0790-51,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,140.59,140.59,241.75,,,,,,00338-1089-04 - Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) IV Sol 2000 mL [REEV],,0250,00338-1089-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],247,185.25,185.25,126.53,103.49,144.41,,,,,,00781-9273-95 - ampicillin 2 g Inj [REEV],J0290,0250,00781-9273-95,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,40.84,40.84,154.11,,,,,,00006-4981-00 - hepatitis B pediatric vaccine 5 mcg/0.5 mL Sus (TVFC) [REEV],,0250,00006-4981-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,97597,Tissue removal from wounds per session (first 20 sq cm or less) [HCPCS 97597],709,531.75,531.75,85.58,85.58,468.8,,,,,,63323-0229-30 - protamine 10 mg/mL Inj Sol [REEV],J2720,0250,63323-0229-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,13.07,10.32,28.14,,,,,,00409-3795-01 - ketorolac 30.,J1885,0250,00409-3795-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,36.22,35.11,337.46,,,,,,60505-3877-03 - dutasteride 0.5 mg Cap [REEV],,0250,60505-3877-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,70.45,70.45,319.43,,,,,,00006-4681-00 - measles/mumps/rubella virus vaccine SubQ Inj [REEV],,0250,00006-4681-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,20.97,2.2,117.5,,,,,,51079-0294-20 - tamsulosin 0.4 mg Oral Cap [REEV],,0250,51079-0294-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,39.1,39.1,434.06,,,,,,00093-6815-73 - budesonide 0.25 mg/2 mL Inh Susp [REEV],J7626,0250,00093-6815-73,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,61.48,61.48,2109.82,,,,,,59762-3140-01 - azithromycin 200 mg/5 mL Oral Liq (bottle) [REEV],,0250,59762-3140-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,165.55,50,3116.59,,,,,,00143-9931-25 - cefotaxime 1 g Inj [REEV],J0698,0250,00143-9931-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,271.84,62.92,1098.7,,,,,,00517-0401-25 - atropine 0.4 mg/mL Inj Sol [REEV],J0461,0250,00517-0401-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,A9150,Misc/exper non-prescript dru [HCPCS A9150],3,2.25,2.25,0.94,0.94,0.94,,,,,,67457-0438-10 - vecuronium 10 mg IV Inj [REEV],J3490,0250,67457-0438-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,C9803,Hopd covid-19 spec collect [HCPCS C9803],64.7,48.53,48.53,37.54,37.54,37.54,,,,,,55513-0002-04 - darbepoetin alfa 25 mcg/mL Inj Sol (PHS) [REEV],J0882,0250,55513-0002-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,22.64,2.42,250.2,,,,,,50419-0422-01 - levonorgestrel 13.5 mg [REEV],J7301,0250,50419-0422-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,5.83,5.83,3301.98,,,,,,00409-1144-01 - verapamil 2.5 mg/mL IV Sol [REEV],,0250,00409-1144-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,7.4,7.4,19.63,,,,,,59762-3120-01 - azithromycin 200 mg/5 mL Oral Liq (dose) [REEV],,0250,59762-3120-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,3.22,3.22,2266.54,,,,,,00168-0040-15 - betamethasone Top valerate 0.1% Crm [REEV],,0250,00168-0040-15,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0171,Adrenalin epinephrine inject [HCPCS J0171],2.5,1.88,1.88,0.8,0.8,1.67,,,,,,58160-0820-52 - hepatitis B pediatric vaccine 10 mcg/0.5 mL Sus PEDI [REEV],,0250,58160-0820-52,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0290,Ampicillin 500 mg inj [HCPCS J0290],12.5,9.38,9.38,1.19,1.19,25,,,,,,55513-0004-04 - darbepoetin alfa 60 mcg/mL Inj Sol (PHS) [REEV],J0882,0250,55513-0004-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0295,Ampicillin sulbactam 1.5 gm [HCPCS J0295],21.52,16.14,16.14,3.38,3.38,9.47,,,,,,00004-0802-85 - oseltamivir 30 mg Cap [REEV],,0250,00004-0802-85,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0330,Succinycholine chloride inj [HCPCS J0330],3.95,2.96,2.96,0,1.74,3.04,,,,,,00052-4330-01 - etonogestrel 68 mg SC implant [REEV],J7307,0250,00052-4330-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0360,Hydralazine hcl injection [HCPCS J0360],36,27,27,6.88,6.88,317.84,,,,,,63323-0012-01 - oxytocin 10 units/mL Inj Sol [REEV],J2590,0250,63323-0012-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0500,Dicyclomine injection [HCPCS J0500],240.4,180.3,180.3,84.68,84.68,84.68,,,,,,00409-4911-34 - atropine 0.1 mg/mL 10 mL Inj Sol [REEV],J0461,0250,00409-4911-34,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],31.47,23.6,23.6,23.42,15.1,23.42,,,,,,00338-0117-04 - Lactated Ringers IV Sol 1000 mL [REEV],J7120,0250,00338-0117-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0595,Butorphanol tartrate 1 mg [HCPCS J0595],25,18.75,18.75,3.58,3.58,20,,,,,,00006-4963-41 - zoster vaccine live SC Inj [REEV],,0250,00006-4963-41,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,0,5.5,14.67,,,,,,00006-0573-62 - indinavir 400 mg Cap [REEV],,0250,00006-0573-62,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0694,Cefoxitin sodium injection [HCPCS J0694],25,18.75,18.75,6.27,6.27,15.35,,,,,,51079-0440-20 - levothyroxine 50 mcg (0.05 mg) Tab [REEV],,0250,51079-0440-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,0.68,0.68,2868.2,,,,,,10019-0651-64 - sevoflurane Inh Liq 250 mL [REEV],,0250,10019-0651-64,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0702,Betamethasone acet&sod phosp [HCPCS J0702],3.09,2.32,2.32,3.74,3.63,3.74,,,,,,42023-0123-06 - dantrolene 20 mg IV Inj [REEV],,0250,42023-0123-06,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0743,Cilastatin sodium injection [HCPCS J0743],37.5,28.13,28.13,8.68,8.68,8.68,,,,,,63323-0513-02 - gentamicin 10 mg/mL Inj Sol [REEV],J1580,0250,63323-0513-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0744,Ciprofloxacin iv [HCPCS J0744],10,7.5,7.5,0.99,0.99,4.8,,,,,,00409-9158-01 - phytonadione 10 mg/mL Inj Sol [REEV],J3430,0250,00409-9158-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,13.53,13.53,65.14,,,,,,17478-0050-01 - SUFentanil 50 mcg/mL IV Sol [REEV],,0250,17478-0050-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,0.17,0.11,332.88,,,,,,00338-0047-47 - sodium chloride 0.9% Irr Sol 3000 mL [REEV],,0250,00338-0047-47,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J1170,Hydromorphone injection [HCPCS J1170],25,18.75,18.75,6.72,6.72,6.72,,,,,,68084-0617-01 - escitalopram 10 mg Tab [REEV],,0250,68084-0617-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,2.1,2.1,2819.66,,,,,,49281-0589-05 - meningococcal conjugate vaccine IM Sol (PHS) [REEV],,0250,49281-0589-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J1630,Haloperidol injection [HCPCS J1630],25,18.75,18.75,1.08,1.08,29.34,,,,,,49281-0278-10 - diphtheria-tetanus toxoids pediatric IM Susp 0 mL [REEV],,0250,49281-0278-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J1650,Inj enoxaparin sodium [HCPCS J1650],14.44,10.83,10.83,1.34,0.47,8.78,,,,,,00904-6554-61 - traZODone 50 mg Tab [REEV],,0250,00904-6554-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,0,5.5,1162.88,,,,,,00173-0682-24 - albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [REEV],,0250,00173-0682-24,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0.73,0.73,808.23,,,,,,60505-0749-04 - ceFAZolin 1. g Powder-Inj,J0690,0250,60505-0749-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,0,7.08,29.34,,,,,,68462-0157-13 - ondansetron 4 mg Dis Tab [REEV],,0250,68462-0157-13,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,7.8,7.8,30.4,,,,,,00884-6297-30 - phenol topical 98%,,0250,00884-6297-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,0,5.5,14.67,,,,,,49281-0215-10 - tetanus-diphth toxoids (Td) adult/adol 5 units-2 units/0.5 mL preservative-free Sus UD [REEV],,0250,49281-0215-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,3.15,3.15,30.39,,,,,,00338-0671-04 - Dextrose 5% with 0.45% NaCl and KCl 20 mEq/l IV Sol 1000 mL [REEV],,0250,00338-0671-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,0,11,29.34,,,,,,00024-1348-03 - phenylephrine nasal 0.25% Sol 15 mL [REEV],,0250,00024-1348-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,0.95,0.95,3583.7,,,,,,00904-5496-46 - nitroglycerin 0.4 mg/hr Transderm ER Film [REEV],,0250,00904-5496-46,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,1.72,1.72,16.28,,,,,,68850-0012-02 - ethambutol 400 mg Tab [REEV],,0250,68850-0012-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,2.81,2.81,811.33,,,,,,00009-0011-04 - hydrocortisone 100 mg preservative-free Pow [REEV],J1710,0250,00009-0011-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0,0.55,29.34,,,,,,65862-0146-36 - SUMAtriptan 25 mg Tab [REEV],,0250,65862-0146-36,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2920,Methylprednisolone injection [HCPCS J2920],25,18.75,18.75,5.3,5.3,21.25,,,,,,66553-0004-01 - calcium carbonate 500 mg Chew Tab [REEV],,0250,66553-0004-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,5.49,5.49,347.63,,,,,,00006-4943-00 - pneumococcal 23-valent vaccine Inj Sol 0 mL [REEV],,0250,00006-4943-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],8.33,6.25,6.25,0,5.12,5.12,,,,,,00904-6101-61 - clonazePAM 0.5 mg Tab [REEV],,0250,00904-6101-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J3030,Sumatriptan succinate / 6 mg [HCPCS J3030],212.5,159.38,159.38,87.42,87.42,179.73,,,,,,00573-0558-07 - witch hazel topical 50% [REEV],,0250,00573-0558-07,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,1.49,1.29,348.28,,,,,,00409-4887-10 - sterile water 10 mL Inj Sol [REEV],,0250,00409-4887-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,5.84,5.5,19.14,,,,,,00078-0659-35 - sacubitril-valsartan 24 mg-26 mg Tab UD [REEV],,0250,00078-0659-35,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],20,15,15,0.84,0.84,14.68,,,,,,62559-0390-20 - vancomycin 125 mg Cap [REEV],,0250,62559-0390-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],35,26.25,26.25,4.71,4.71,4.71,,,,,,57896-0901-01 - aspirin 325 mg Tab [REEV],,0250,57896-0901-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,1.66,1.66,23.47,,,,,,58232-0400-29 - bacitracin/neomycin/polymyxin B Top Oint (pkt) [REEV],,0250,58232-0400-29,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,1.76,23.48,,,,,,68084-0808-01 - traMADol 50 mg Tab [REEV],,0250,68084-0808-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,0.02,0.02,4433.9,,,,,,"63851-0501-02 - rabies vaccine, purified chick embyro cell 2.5 intl units IM Inj [REEV]",,0250,63851-0501-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7510,Prednisolone oral per 5 mg [HCPCS J7510],10.36,7.77,7.77,2.49,2.49,8.81,,,,,,60505-0141-00 - glipiZIDE 5 mg Tab [REEV],,0250,60505-0141-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,0,2.4,4.25,,,,,,51079-0437-20 - doxepin 25 mg Cap [REEV],,0250,51079-0437-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7614,Levalbuterol non-comp unit [HCPCS J7614],5.58,4.19,4.19,0,3.39,5.7,,,,,,12870-0001-01 - silver nitrate Top Stick [REEV],,0250,12870-0001-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,J7620,Albuterol ipratrop non-comp [HCPCS J7620],5.47,4.1,4.1,0,2.41,4.65,,,,,,68084-0189-01 - zolpidem 5 mg Tab [REEV],,0250,68084-0189-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,167.53,167.53,728.8,,,,,,00713-0536-12 - promethazine 12.5 mg Supp [REEV],,0250,00713-0536-12,,,
SUPERIOR HEALTH PLAN - Medicaid,Hospital,Institutional,Outpatient,S0028,"Injection, famotidine, 20 mg [HCPCS S0028]",29.93,22.45,22.45,2.61,2.61,2.61,,,,,,"00009-0233-03 - bacitracin 50,000 units IM Inj [REEV]",,0250,00009-0233-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,940,"Anesthesia provided during vaginal biopsy of cervix, uterine lining, or external genitalia [HCPCS 00940]",926.1,694.58,694.58,156.62,156.62,156.62,,,,,,"00338-0519-09 - Fat Emul, 20% IV 250 mL [REEV]",,0250,00338-0519-09,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,948,Anesthesia provided during suture closure of cervix [HCPCS 00948],1058.4,793.8,793.8,170.05,38.26,170.05,,,,,,00168-0258-15 - betamethasone-clotrimazole Top 0.05%-1% Crm [REEV],,0250,00168-0258-15,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],361.7,271.28,271.28,73.08,73.08,424.53,,,,,,00409-3977-03 - sterile water bacteriostatic Inj Sol 30 mL [REEV],,0250,00409-3977-03,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,36.22,35.11,337.46,,,,,,00781-6156-52 - amoxicillin 200 mg/5 mL Oral Liq [REEV],,0250,00781-6156-52,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",314,235.5,235.5,55.67,55.67,329.7,,,,,,50383-0778-16 - ferrous sulfate 220 mg/5 mL Oral Elix [REEV],,0250,50383-0778-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],194.3,145.73,145.73,73.93,73.93,98.64,,,,,,63739-0559-10 - ciprofloxacin 500 mg Tab [REEV],,0250,63739-0559-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],83,62.25,62.25,35.71,35.71,43.32,,,,,,00591-5786-01 - nortriptyline 10 mg Cap [REEV],,0250,00591-5786-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99465,Newborn resuscitation at delivery [HCPCS 99465],479.7,359.78,359.78,138.98,138.98,151.06,,,,,,67457-0447-53 - flumazenil 0.5,,0250,67457-0447-53,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,790,Anesthesia provided during procedure in upper abdomen with use of an endoscope [HCPCS 00790],139,104.25,104.25,425.11,1.97,425.11,,,,,,00338-1049-02 - nitroglycerin 20 mg/100 mL-D5W IV Sol [REEV],,0250,00338-1049-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,800,Anesthesia provided during procedure on lower front abdominal wall [HCPCS 00800],139,104.25,104.25,201.37,201.37,201.37,,,,,,00338-1113-04 - Amino Acids 4.25% with 5% Dextrose and Electrolytes (Clinimix E Sulfite-Free) IV Sol 2000 mL [REEV],,0250,00338-1113-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,851,Anesthesia provided during tying or incision of fallopian tubes using an endoscope [HCPCS 00851],139,104.25,104.25,268.49,5.72,268.49,,,,,,"00049-0530-28 - Penicillin G Potassium 20,000,000 units Pow [REEV]",J2540,0250,00049-0530-28,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,13.59,3.36,245.34,,,,,,00206-8854-16 - piperacillin-tazobactam 3 g-0.375 g IV Inj [REEV],J2543,0250,00206-8854-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,1968,Anesthesia provided during cesarean delivery following labor [HCPCS 01968],139,104.25,104.25,188.42,2.99,188.42,,,,,,17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [REEV],,0250,17478-0515-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,22903,Abdominal wall tissue tumor removal beneath the skin (3 cm or greater) [HCPCS 22903],1569,1176.75,1176.75,355.89,355.89,355.89,,,,,,00904-6500-61 - fluconazole 100 mg Tab [REEV],,0250,00904-6500-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,31500,Breathing tube insertion into windpipe cartilage with endoscope (emergent) [HCPCS 31500],139,104.25,104.25,95.08,95.08,227.35,,,,,,63323-0010-02 - gentamicin 40 mg/mL Inj Sol [REEV],J1580,0250,63323-0010-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,49652,Abdominal or navel hernia repair with endoscope (herniated tissue that is not trapped) [HCPCS 49652],2678.1,2008.58,2008.58,579.78,579.78,579.78,,,,,,00641-0367-25 - dexamethasone 10 mg/mL Inj Sol [REEV],J1100,0250,00641-0367-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,79.71,79.43,766.3,,,,,,50633-0120-11 - digoxin immune FAB 40 mg Inj [REEV],J1162,0250,50633-0120-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,58301,Intra-uterine device (IUD) removal for pregnancy prevention [HCPCS 58301],169.9,127.43,127.43,114.89,114.89,150.82,,,,,,63323-0026-05 - sodium bicarbonate 4.2%,,0250,63323-0026-05,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],7445.3,5583.98,5583.98,249.93,127.52,393.81,,,,,,00023-0506-01 - ocular lubricant Sol [REEV],,0250,00023-0506-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,58611,Fallopian tubes tying or incision at time of cesarean delivery or other abdominal surgery [HCPCS 58611],423.4,317.55,317.55,9.22,9.22,121.22,,,,,,00904-5676-61 - PARoxetine 10 mg Tab [REEV],,0250,00904-5676-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,58671,Blocking of uterine tubes by device with endoscope [HCPCS 58671],1591,1193.25,1193.25,275.86,275.86,577.59,,,,,,00409-1560-10 - bupivacaine 0.5% PF Inj Sol 10 mL [REEV],S0020,0250,00409-1560-10,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,22.99,22.99,68.3,,,,,,00409-1966-07 - sodium chloride bacteriostatic 0.9% Inj Sol 30 mL [REEV],,0250,00409-1966-07,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,583.91,583.91,1462.85,,,,,,13533-0684-20 - albumin human 25% IV Sol 50 mL [REEV],,0250,13533-0684-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,59414,Placenta removal after delivery of infant [HCPCS 59414],583.3,437.48,437.48,0,67.92,67.92,,,,,,16729-0002-01 - glimepiride 2 mg Tab [REEV],,0250,16729-0002-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,660.25,138.2,1470.79,,,,,,63323-0540-31 - heparin 1000 units/mL Inj Sol (PHS) [REEV],J1644,0250,63323-0540-31,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,214.38,214.38,2255.8,,,,,,00409-1463-01 - nalbuphine 10 mg/mL Inj Sol [REEV],J2300,0250,00409-1463-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,45.56,45.56,141.93,,,,,,00409-3505-01 - meropenem 500 mg IV Inj [REEV],J2185,0250,00409-3505-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,14.96,8.98,23.86,,,,,,00555-0071-02 - isoniazid 300 mg Tab [REEV],,0250,00555-0071-02,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,22.59,13.55,72.8,,,,,,00338-0077-04 - Dextrose 5% with 0.2% NaCl IV Sol 1000 mL [REEV],,0250,00338-0077-04,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,58.08,52.38,170.1,,,,,,00574-0120-76 - charcoal-sorbitol 50 g Oral Susp 240 mL [REEV],,0250,00574-0120-76,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,52.53,52.53,206.9,,,,,,58914-0080-52 - dicyclomine 10 mg/mL Inj Sol [REEV],J0500,0250,58914-0080-52,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,90.59,81.71,178.67,,,,,,00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [REEV],,0250,00904-5894-30,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],371.6,278.7,278.7,122.95,122.95,194.97,,,,,,00781-3125-85 - nafcillin 2 g Inj [REEV],,0250,00781-3125-85,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,59.92,59.92,194.57,,,,,,76204-0600-60 - albuterol-ipratropium Inh Sol 3 mL [REEV],J7620,0250,76204-0600-60,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,95.05,95.05,222.03,,,,,,24385-0149-76 - lactase Tab [REEV],,0250,24385-0149-76,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,120.14,120.14,248.05,,,,,,00409-1215-01 - naloxone 0.4 mg/mL Inj Sol [REEV],J2310,0250,00409-1215-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,22.37,22.37,41.75,,,,,,58160-0820-11 - hepatitis B pediatric vaccine 10 mcg/0.5 mL Sus (TVFC) PEDI [REEV],,0250,58160-0820-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,41.53,39.55,134.08,,,,,,00641-6054-25 - meperidine 100 mg/mL Inj Sol [REEV],J2175,0250,00641-6054-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,31.68,31.68,51.15,,,,,,39328-0048-16 - hyoscyamine 0.125 mg/5 mL Oral Liq (bottle) [REEV],,0250,39328-0048-16,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,45.48,45.48,91.29,,,,,,00093-3107-01 - amoxicillin 250 mg Cap [REEV],,0250,00093-3107-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,114.76,114.76,176.55,,,,,,51079-0905-20 - phenytoin 100 mg ERCap [REEV],,0250,51079-0905-20,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99235,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235],458.7,344.03,344.03,142.98,142.98,177.83,,,,,,42858-0301-25 - HYDROmorphone 2 mg Tab [REEV],,0250,42858-0301-25,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99236,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of high severity (55 minutes per day) [HCPCS 99236],568.9,426.68,426.68,191.28,191.28,228.53,,,,,,00487-9801-60 - ipratropium 0.02% Inh Sol 2 mL [REEV],J7644,0250,00487-9801-60,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,60.51,59.99,274.04,,,,,,16729-0030-01 - methyldopa 250 mg Tab [REEV],,0250,16729-0030-01,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,72.15,33.41,326.4,,,,,,60432-0131-08 - phenytoin 125 mg/5 mL Oral Susp [REEV],,0250,60432-0131-08,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,80.36,77,101.03,,,,,,00904-1228-00 - diphenhydrAMINE 12.5 mg/5 mL Oral Liq (bottle) [REEV],,0250,00904-1228-00,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,38.82,38.82,44.36,,,,,,00904-5392-61 - atenolol 25 mg Tab [REEV],,0250,00904-5392-61,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99464,Newborn delivery and stabilization with physician attendance [HCPCS 99464],211.7,158.78,158.78,89.75,79.03,89.75,,,,,,58160-0818-11 - haemophilus b conjugate (PRP-T) vaccine IM Inj (PHS) [REEV],,0250,58160-0818-11,,,
SUPERIOR HEALTH PLAN - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99465,Newborn resuscitation at delivery [HCPCS 99465],412.4,309.3,309.3,151.06,151.06,151.06,,,,,,00006-4992-00 - hepatitis B adult vaccine dialysis 40 mcg/mL Sus (PHS) [REEV],,0250,00006-4992-00,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,298.93,70.45,319.43,,,,,,00574-0412-07 - polyethylene glycol 3350 Oral Pwdr for Recon [REEV],,0250,00574-0412-07,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,49082,Abdominal cavity fluid drainage [HCPCS 49082],2166.3,1624.73,1624.73,70.35,55,70.35,,,,,,00338-0077-03 - Dextrose 5% with 0.2% NaCl IV Sol 500 mL [REEV],,0250,00338-0077-03,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,137.42,8.87,355.2,,,,,,68084-0371-01 - amiodarone 200 mg Tab [REEV],,0250,68084-0371-01,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,83.17,11.25,148.9,,,,,,68084-0204-01 - minoxidil 2.5 mg Tab [REEV],,0250,68084-0204-01,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,64.74,8.16,104.31,,,,,,00409-4276-01 - lidocaine 1%,J2001,0250,00409-4276-01,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,157.69,32.98,268.8,,,,,,51672-1267-05 - triamcinolone Top 0.1% Paste [REEV],,0250,51672-1267-05,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,0,18.45,315.4,,,,,,00054-0108-25 - ramipril 5 mg Cap [REEV],,0250,00054-0108-25,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,75.8,14.11,134.34,,,,,,63323-0690-30 - acetylcysteine 20% Sol 30 mL [REEV],J7608,0250,63323-0690-30,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.26,6,88.2,,,,,,00409-2337-25 - deferoxamine 2 g Inj [REEV],J0895,0250,00409-2337-25,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.83,6.15,4344.87,,,,,,39822-0310-05 - neomycin 500 mg Tab [REEV],,0250,39822-0310-05,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-Indemnity",,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,2143.01,214.38,2255.8,,,,,,00904-6442-61 - hydrALAZINE 50 mg Tab [REEV],,0250,00904-6442-61,,,
ALLISON CRANE & RIGGING - Commercial-PPO,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,75.62,45.56,141.93,,,,,,00409-6533-01 - vancomycin 1. g Powder-Inj,J3370,0250,00409-6533-01,,,
ALLISON CRANE & RIGGING - Commercial-PPO,,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,109.78,91.42,145.6,,,,,,76045-0006-10 - morphine,J2270,0250,76045-0006-10,,,
TML HEALTH - Commercial-Mut Defined,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,"49281-0400-10 - tetanus/diphtheria/pertussis, acel (Tdap) Susp",,0250,49281-0400-10,,,
TML HEALTH - Commercial-Mut Defined,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,00338-0683-04 - Dextrose 5% in Water with KCl 20 mEq/l IV Sol 1000 mL [REEV],,0250,00338-0683-04,,,
TML HEALTH - Commercial-Mut Defined,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,00338-0049-48 - Sodium Chloride 0.9% IV Sol 100 mL [REEV],,0250,00338-0049-48,,,
TML HEALTH - Commercial-Mut Defined,,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,00075-8030-01 - enoxaparin 300 mg/3 mL [REEV],J1650,0250,00075-8030-01,,,
TML HEALTH - Commercial-PPO,,Professional,Outpatient,31500,Breathing tube insertion into windpipe cartilage with endoscope (emergent) [HCPCS 31500],139,104.25,104.25,0,95.08,227.35,,,,,,51079-0051-20 - pantoprazole 40 mg Oral EC Tab [REEV],,0250,51079-0051-20,,,
TML HEALTH - Commercial-PPO,,Professional,Outpatient,36556,Non-tunneled central venous catheter insertion for infusion (5 years of age or older) [HCPCS 36556],1225,918.75,918.75,167.19,167.19,167.19,,,,,,00904-6341-61 - metoprolol 50 mg Tab [REEV],,0250,00904-6341-61,,,
TML HEALTH - Commercial-PPO,,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,248.05,120.14,248.05,,,,,,50419-0421-01 - levonorgestrel 52. mg,,0250,50419-0421-01,,,
TML HEALTH - Commercial-PPO,,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,51.15,31.68,51.15,,,,,,00713-0503-12 - hydrocortisone 25 mg Supp [REEV],,0250,00713-0503-12,,,
TML HEALTH - Commercial-PPO,,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,91.29,45.48,91.29,,,,,,76045-0009-05 - HYDROmorphone,J1170,0250,76045-0009-05,,,
TML HEALTH - Commercial-PPO,,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],257,192.75,192.75,130.9,99.96,130.9,,,,,,63323-0368-20 - ampicillin-sulbactam 1 g-0.5 g Inj [REEV],J0295,0250,63323-0368-20,,,
TML HEALTH - Commercial-PPO,,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,93.5,59.99,274.04,,,,,,00338-0049-02 - Sodium Chloride 0.9% IV Sol 250 mL [REEV],J7050,0250,00338-0049-02,,,
TML HEALTH - Commercial-PPO,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.34,2.66,8.7,,,,,,17478-0503-05 - ethanol 98% Inj Sol 5 mL [REEV],,0250,17478-0503-05,,,
TML HEALTH - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,225.03,61.48,2109.82,,,,,,39822-5525-03 - promethazine 25.,J2550,0250,39822-5525-03,,,
UMR UNITED HEAL - Commercial-PPO,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,95.52,61.63,100.1,,,,,,60505-0094-00 - doxazosin 2 mg Tab [REEV],,0250,60505-0094-00,,,
UMR UNITED HEAL - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,00517-5602-25 - hydrOXYzine hydrochloride 50 mg/mL 2 mL IM Sol [REEV],,0250,00517-5602-25,,,
UMR UNITED HEAL - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,51.31,51.31,199.63,,,,,,00338-0017-31 - Dextrose 5% in Water IV Sol 50 mL [REEV],,0250,00338-0017-31,,,
UMR UNITED HEAL - Commercial-PPO,Hospital,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,95.52,61.63,100.1,,,,,,00065-0741-12 - tetracaine ophthalmic 0.5%,,0250,00065-0741-12,,,
UMR UNITED HEAL - Commercial-PPO,Hospital,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,51079-0172-20 - metFORMIN 500 mg Tab [REEV],,0250,51079-0172-20,,,
UMR - Commercial-PPO,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,95.33,4.51,1156.79,,,,,,"63851-0501-01 - rabies vaccine, purified chick embryo cell 2.5 IntlUnit Powder-Inj",,0250,63851-0501-01,,,
UMR - Commercial-PPO,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],230.5,172.88,172.88,89.65,80.15,262.94,,,,,,00280-4100-36 - citric acid/potassium bicarbonate/Na bicarb 1000 mg-344 mg-1050 mg [REEV],,0250,00280-4100-36,,,
UMR - Commercial-PPO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,53.91,35.11,337.46,,,,,,00008-4001-25 - pantoprazole 40 mg IV Inj [REEV],,0250,00008-4001-25,,,
UMR - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,86.35,70.45,319.43,,,,,,"49281-0712-40 - influenza virus vaccine, inactivated preservative-free quadrivalent Sus [REEV]",,0250,49281-0712-40,,,
UMR - Commercial-PPO,Clinic,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,0,0.11,332.88,,,,,,"49281-0399-65 - influenza virus vaccine, inactivated high-dose preservative-free trivalent Sus [REEV]",,0250,49281-0399-65,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,20605,Medium joint or joint capsule fluid removal and/or injection with needle [HCPCS 20605],314.4,235.8,235.8,78.64,51.9,80.44,,,,,,54482-0147-01 - levOCARNitine 200 mg/mL Inj Sol (PHS) [REEV],J1955,0250,54482-0147-01,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,100.1,61.63,100.1,,,,,,50458-0580-10 - rivaroxaban 10 mg Tab UD [REEV],,0250,50458-0580-10,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.14,2.07,19.9,,,,,,36000-0283-25 - furosemide 10 mg/mL 4 mL Inj Sol [REEV],J1940,0250,36000-0283-25,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.3,5.3,61.31,,,,,,00832-0302-00 - chlorproMAZINE 50. mg Tab,,0250,00832-0302-00,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,14,12.82,82,,,,,,00904-1982-61 - acetaminophen 325 mg Tab [REEV],,0250,00904-1982-61,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,00338-0023-02 - Dextrose 10% in Water IV Sol 250 mL [REEV],,0250,00338-0023-02,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,304.17,156.33,346.97,,,,,,51079-0923-20 - carbidopa-levodopa 50 mg-200 mg ER Tab [REEV],,0250,51079-0923-20,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,20.95,15.77,25,,,,,,50383-0700-16 - fluticasone Nasal 0.05 mg/inh Spry [REEV],,0250,50383-0700-16,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,53.67,36.98,63.97,,,,,,"63323-0482-17 - EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 10 mL [REEV]",J0171,0250,63323-0482-17,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,161.57,134.02,193.88,,,,,,50383-0775-04 - lidocaine topical 2%,,0250,50383-0775-04,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,00169-3687-12 - insulin detemir 100 units/mL SC Sol [REEV],J1815,0250,00169-3687-12,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,89.65,45.56,141.93,,,,,,24385-0675-10 - magnesium citrate 8.85% Oral Liq 300 mL [REEV],,0250,24385-0675-10,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,131.45,91.42,145.6,,,,,,76439-0343-30 - potassium chloride 20 mEq Oral Pwdr [REEV],,0250,76439-0343-30,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],281.2,210.9,210.9,251.35,185.38,251.35,,,,,,51672-1298-01 - ketoconazole Top 2% Crm [REEV],,0250,51672-1298-01,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,00904-5785-61 - FLUoxetine 20 mg Cap [REEV],,0250,00904-5785-61,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,00409-1754-10 - magnesium sulfate 50%,J3475,,00409-1754-10,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,00003-0893-31 - apixaban 2.5 mg Tab [REEV],,0250,00003-0893-31,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,175.45,147.2,226.48,,,,,,50242-0085-27 - alteplase 100 mg IV Inj (PHS) [REEV],J2997,0250,50242-0085-27,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,00338-0081-03 - Dextrose 5% with 0.33% NaCl IV Sol 500 mL [REEV],,0250,00338-0081-03,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,00409-2051-05 - ketamine 100 mg/mL Inj Sol [REEV],,0250,00409-2051-05,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,15.12,14.35,372.57,,,,,,00781-6039-58 - amoxicillin 125 mg/5 mL Oral Liq (BOTTLE) [REEV],,0250,00781-6039-58,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,00713-0102-09 - glycerin pediatric Supp [REEV],,0250,00713-0102-09,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,63739-0119-10 - glyBURIDE 5 mg Tab [REEV],,0250,63739-0119-10,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,51079-0210-20 - atorvastatin 40 mg Tab [REEV],,0250,51079-0210-20,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],26.3,19.73,19.73,1.11,1.11,2.45,,,,,,00904-7591-61 - ferrous sulfate 325 mg Tab [REEV],,0250,00904-7591-61,,,
UMR - Commercial-PPO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,17.76,1.1,17.76,,,,,,78112-0011-06 - benzocaine-menthol topical 6 mg-10 mg Loz [REEV],,0250,78112-0011-06,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,76.75,55,125,,,,,,65649-0201-75 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 1 EA [REEV],,0250,65649-0201-75,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.76,2.44,580.94,,,,,,00409-1893-01 - morphine 10 mg/mL preservative-free [REEV],J2274,0250,00409-1893-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,955.9,137.3,1347.57,,,,,,"49281-0625-15 - influenza virus vaccine, inactivated quadrivalent Sus [REEV]",,0250,49281-0625-15,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,798.43,73.48,1221.85,,,,,,68084-0446-01 - nitrofurantoin macrocrystals-monohydrate 100 mg Cap [REEV],,0250,68084-0446-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,152.24,20.71,250.4,,,,,,00338-0049-03 - Sodium Chloride 0.9% IV Sol 500 mL [REEV],J7040,0250,00338-0049-03,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,164.95,28.74,271.3,,,,,,00591-4012-01 - valproic acid 250 mg Cap [REEV],,0250,00591-4012-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,804.38,137.3,1124.55,,,,,,00338-0049-04 - Sodium Chloride 0.9% IV Sol 1000 mL [REEV],,0250,00338-0049-04,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1412.4,1059.3,1059.3,817.82,272.21,898.39,,,,,,50383-0040-04 - prednisoLONE sodium phosphate 5 mg/5 mL Oral Liq [REEV],J7510,0250,50383-0040-04,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],246,184.5,184.5,149.57,107.22,162.99,,,,,,00832-7123-01 - divalproex sodium 250 mg Oral EC Tab [REEV],,0250,00832-7123-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,136.8,69.84,223.7,,,,,,51285-0204-01 - copper - [REEV],J7300,0250,51285-0204-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,792.35,166.13,1107.72,,,,,,"45802-0059-35 - nystatin Top 100,000 units/g Crm [REEV]",,0250,45802-0059-35,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,804.38,166.13,1309.77,,,,,,00338-0117-03 - Lactated Ringers IV Sol 500 mL [REEV],J7120,0250,00338-0117-03,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,136.8,99,166.13,,,,,,25021-0106-10 - cefTRIAXone 1 g Inj [REEV],J0696,0250,25021-0106-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,136.8,57.76,225,,,,,,31722-0726-30 - montelukast 10 mg Tab [REEV],,0250,31722-0726-30,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,136.8,94.25,214.2,,,,,,58160-0821-11 - hepatitis B adult vaccine 20 mcg/mL Sus [REEV],,0250,58160-0821-11,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,136.8,56.37,178.99,,,,,,00409-4902-34 - dextrose 50% IV Sol 50 mL [REEV],,0250,00409-4902-34,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,136.8,37.7,213.75,,,,,,17478-0711-10 - lidocaine Top 2% Gel w/Appl [REEV],,0250,17478-0711-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],225,168.75,168.75,136.8,94.25,148.78,,,,,,16252-0616-30 - rosuvastatin 10. mg Tab,,0250,16252-0616-30,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],1046.4,784.8,784.8,636.21,350.85,636.21,,,,,,"00409-3183-01 - EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [REEV]",,0250,00409-3183-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1513.62,180.22,3324.06,,,,,,68084-0895-01 - acetaminophen-HYDROcodone 325 mg-5 mg Tab [REEV],,0250,68084-0895-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1526.38,561.23,2500,,,,,,00071-1013-41 - pregabalin 50 mg oral capsule [REEV],,0250,00071-1013-41,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,454.48,110.94,589.78,,,,,,68084-0863-01 - acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [REEV],,0250,68084-0863-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,256.09,166.13,421.2,,,,,,00046-1102-81 - conjugated estrogens 0.625 mg Tab [REEV],,0250,00046-1102-81,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,397.57,166.13,529.3,,,,,,00591-0810-83 - silver sulfADIAZINE Top 1% Crm [REEV],,0250,00591-0810-83,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,454.48,92.55,635.38,,,,,,00338-1146-03 - Amino Acids 4.25% with 25% Dextrose and Electrolytes (Clinimix E Sulfite-Free) IV Sol 1000 mL [REEV],,0250,00338-1146-03,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,295.3,108.36,412.85,,,,,,"59676-0310-01 - epoetin alfa 10,000 units/mL preservative-free (PHS) [REEV]",J0885,0250,59676-0310-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,97.89,8.49,161,,,,,,63323-0165-01 - dexamethasone 4 mg/mL 1 mL Inj Sol [REEV],J1100,0250,63323-0165-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,65162-0057-03 - raloxifene 60 mg Tab [REEV],,0250,65162-0057-03,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,90.53,11.25,148.9,,,,,,50242-0041-64 - alteplase 2 mg IV Inj (PHS) [REEV],J2997,0250,50242-0041-64,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,280.9,48.41,364.52,,,,,,00338-0675-04 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [REEV],,0250,00338-0675-04,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,112.66,8.3,183.45,,,,,,57896-0921-01 - aspirin 325 mg Oral EC Tab [REEV],,0250,57896-0921-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,181,14.4,297.7,,,,,,59212-0423-16 - atropine/hyoscyamine/PB/scopolamine Elixir,,0250,59212-0423-16,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,52.29,9.42,73.71,,,,,,42023-0104-05 - tuberculin purified protein derivative 5 TU/0.1 mL ID 5 mL Sol [REEV],,0250,42023-0104-05,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,285.09,9.63,285.09,,,,,,68084-0357-21 - rifampin 150 mg Cap [REEV],,0250,68084-0357-21,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,46.33,2.66,76.2,,,,,,68094-0494-61 - ibuprofen 100 mg/5 mL Oral Susp [REEV],,0250,68094-0494-61,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,32.22,1.89,53,,,,,,67919-0011-01 - DAPTOmycin 500. mg Powder-Inj,,0250,67919-0011-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,49.61,6.2,81.6,,,,,,00003-0293-20 - triamcinolone 200. Susp,,0250,00003-0293-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82010,"Lab analysis to measure the amount of ketone bodies in blood, serum, or plasma specimen [HCPCS 82010]",75.6,56.7,56.7,27.75,8.3,45.2,,,,,,00641-6053-25 - meperidine 50 mg/mL Inj Sol [REEV],J2175,0250,00641-6053-25,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,16.11,2.31,20.91,,,,,,68084-0550-01 - rivastigmine 1.5 mg Cap [REEV],,0250,68084-0550-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,290.1,30.08,290.1,,,,,,36000-0282-25 - furosemide 10 mg/mL 2 mL Inj Sol [REEV],J1940,0250,36000-0282-25,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82530,Lab analysis to measure the amount of free cortisol (hormone) [HCPCS 82530],237.1,177.83,177.83,142.15,16.71,233.8,,,,,,00904-6358-61 - risperiDONE 0.5 mg Tab [REEV],,0250,00904-6358-61,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,39.58,5.81,65.1,,,,,,00409-7241-01 - EPINEPHrine 1 mg/mL Inj Sol [REEV],J0171,0250,00409-7241-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,59.04,4.35,81.23,,,,,,00338-0705-48 - potassium chloride 20 mEq/100 mL IV Sol [REEV],,0250,00338-0705-48,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,75.82,12.67,98.39,,,,,,00143-9725-01 - progesterone 50 mg/mL IM Sol [REEV],J2675,0250,00143-9725-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,282.9,32.34,465.3,,,,,,00536-2790-59 - Multiple Vitamins with Minerals Oral Liq 240 mL [REEV],,0250,00536-2790-59,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82672,Lab analysis to identify total estrogen [HCPCS 82672],255.8,191.85,191.85,155.53,155.53,255.8,,,,,,25021-0132-82 - levofloxacin 500 mg/100 mL IV Sol [REEV],J1956,0250,25021-0132-82,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,71.81,11.45,112.4,,,,,,63739-0522-10 - aspirin 81 mg Oral EC Tab [REEV],,0250,63739-0522-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.59,2.66,8.7,,,,,,00006-3516-59 - imipenem-cilastatin 500 mg Inj [REEV],J0743,0250,00006-3516-59,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,134.06,16.1,220.5,,,,,,00409-1626-01 - butorphanol 2 mg/mL Inj Sol [REEV],J0595,0250,00409-1626-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",399.1,299.33,299.33,108.59,18.83,178.6,,,,,,25021-0132-83 - levofloxacin 750 mg/150 mL IV Sol [REEV],J1956,0250,25021-0132-83,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,70.47,8.16,104.31,,,,,,66553-0002-01 - aspirin 81 mg Chew Tab [REEV],,0250,66553-0002-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,30.89,5.43,33.59,,,,,,51552-0051-06 - acetic acid Top 3% Sol 473 mL [REEV],,0250,51552-0051-06,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,35.57,7.34,38.68,,,,,,17478-0937-10 - diltiazem 5. mg,J3490,0250,17478-0937-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,118.01,9.72,190.22,,,,,,58160-0826-11 - hepatitis A adult vaccine 1440 units/mL PF IM Susp (PHS) [REEV],,0250,58160-0826-11,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,90.93,5.07,94.54,,,,,,51079-0385-20 - carBAMazepine 200 mg Tab [REEV],,0250,51079-0385-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83655,Lab analysis to measure the lead level in blood specimen [HCPCS 83655],123.5,92.63,92.63,75.09,12.31,122.26,,,,,,25021-0608-51 - propofol 10 mg/mL 100 mL IV Emul [REEV],J2704,0250,25021-0608-51,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,64.39,5,105.9,,,,,,63323-0664-01 - diphenhydrAMINE 50 mg/mL Inj Sol [REEV],J1200,0250,63323-0664-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,171.64,32.98,268.8,,,,,,00496-0892-30 - lidocaine Top 5% Crm [REEV],,0250,00496-0892-30,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84145,Lab analysis to measure the procalcitonin (hormone) level in serum or plasma specimen [HCPCS 84145],398.1,298.58,298.58,232.77,27.66,265.89,,,,,,00046-0749-05 - conjugated estrogens 25 mg IV Inj [REEV],J1410,0250,00046-0749-05,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,112.66,19.44,112.66,,,,,,63323-0130-17 - doxycycline 100 mg IV Inj [REEV],J3490,0250,63323-0130-17,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,191.76,18.45,315.4,,,,,,68084-0093-01 - carbidopa-levodopa 25 mg-100 mg Tab [REEV],,0250,68084-0093-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84402,Lab analysis to measure free testosterone (hormone) level in serum specimen [HCPCS 84402],148.9,111.68,111.68,90.53,25.55,148.9,,,,,,00013-8303-04 - latanoprost Ophth 0.005% Sol [REEV],,0250,00013-8303-04,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,146.16,25.9,240.4,,,,,,00009-0746-35 - medroxyPROGESTERone 150. Susp,,0250,00009-0746-35,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],61.8,46.35,46.35,37.57,11.39,37.57,,,,,,63323-0398-10 - azithromycin 500 mg IV Inj [REEV],J0456,0250,63323-0398-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,79.1,7.58,134.6,,,,,,00409-6482-01 - erythromycin lactobionate 500 mg Inj [REEV],J1364,0250,00409-6482-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,82.51,14.11,134.34,,,,,,17478-0067-02 - alfentanil 0.5 mg/mL Inj Sol [REEV],J3490,0250,17478-0067-02,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,94.54,14.41,153.94,,,,,,00338-1007-02 - DOPamine 1.6 mg/mL-D5W intravenous solution 250 mL [REEV],J1265,0250,00338-1007-02,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,85.85,9.87,141.2,,,,,,68084-0578-21 - lamiVUDine 150 mg Tab [REEV],,0250,68084-0578-21,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,118.68,17.05,191.3,,,,,,00169-7501-11 - insulin aspart 100 units/mL [REEV],J1815,0250,00169-7501-11,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,85.85,12.64,85.85,,,,,,00173-0449-02 - SUMAtriptan 6 mg/0.5 mL SubQ Sol [REEV],J3030,0250,00173-0449-02,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.63,6,88.2,,,,,,54643-5649-01 - Multiple Vitamins IV Sol 10 mL [REEV],,0250,54643-5649-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,22.8,5.43,37.5,,,,,,00071-0418-13 - nitroglycerin 0.4 mg sublingual Tab [REEV],,0250,00071-0418-13,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85045,Lab analysis to measure red blood count (automated test) [HCPCS 85045],100.4,75.3,75.3,61.04,6.62,61.04,,,,,,00264-7612-10 - Dextrose 5% with 0.45% NaCl IV Sol 500 mL [REEV],,0250,00264-7612-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,116.68,8.55,182.7,,,,,,63323-0376-01 - octreotide 100 mcg/mL Inj Sol (PHS) [REEV],J2354,0250,63323-0376-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,42.32,3.6,69.6,,,,,,63323-0083-05 - sodium bicarbonate 4.2% IV Sol 5 mL [REEV],,0250,63323-0083-05,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,41.53,2.7,54.33,,,,,,00009-0039-28 - methylPREDNISolone 40 mg preservative-free Pow [REEV],J2920,0250,00009-0039-28,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,42.32,6.03,69.6,,,,,,00270-1316-35 - iopamidol 76% Inj Sol 100 mL [REEV],,0255,00270-1316-35,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,46.33,5.26,76.2,,,,,,68180-0411-06 - irbesartan 150 mg Tab [REEV],,0250,68180-0411-06,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,61.8,4.34,61.8,,,,,,00603-0235-16 - bismuth subsalicylate 262 mg Chew Tab [REEV],,0250,00603-0235-16,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,121.3,11.52,121.3,,,,,,00093-2027-23 - azithromycin 100 mg/5 mL Oral Liq (bottle) [REEV],,0250,00093-2027-23,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,54.83,16.62,74.01,,,,,,00591-0800-01 - hydrOXYzine pamoate 25 mg Cap [REEV],J1050,0250,00591-0800-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,222.7,11.99,222.7,,,,,,00168-0357-55 - lidocaine-prilocaine Top 2.5%-2.5% Crm [REEV],,0250,00168-0357-55,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,85.85,9.2,112.32,,,,,,00065-0647-05 - dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp,,0250,00065-0647-05,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,60.97,7.24,496.86,,,,,,51293-0626-01 - PHENobarbital 32.4 mg Tab [REEV],,0250,51293-0626-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,58.7,6.79,100.4,,,,,,00407-2223-17 - iodixanol 320 mg/mL Inj Sol [REEV],,0255,00407-2223-17,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,65.72,2.84,108.1,,,,,,00832-2012-00 - amantadine 100 mg Cap [REEV],,0250,00832-2012-00,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,14.49,6.8,52.43,,,,,,00093-6816-73 - budesonide 0.5 mg/2 mL Inh Susp [REEV],J7633,0250,00093-6816-73,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,100.57,7.27,172,,,,,,51672-4002-05 - nortriptyline 25 mg Cap [REEV],,0250,51672-4002-05,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,94.54,8.17,155.5,,,,,,63323-0403-02 - fosphenytoin (PE) 100 mg/2 mL Inj Sol [REEV],,0250,63323-0403-02,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,64.47,37.79,110.3,,,,,,00093-0311-01 - loperamide 2. mg Cap,,0250,00093-0311-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,155.5,29.48,155.5,,,,,,00409-1902-01 - procainamide 100 mg/mL Inj Sol [REEV],J2690,0250,00409-1902-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,155.5,29.48,155.5,,,,,,63323-0694-04 - acetylcysteine 20% Inh Sol 4 mL [REEV],J7608,0250,63323-0694-04,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,10.32,4.29,35.67,,,,,,00904-5711-35 - oxymetazoline Nasal 0.05% Spry [REEV],,0250,00904-5711-35,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,100.56,45.82,378.9,,,,,,00009-3073-01 - methylPREDNISolone acetate 40 mg/mL Inj Susp [REEV],J1030,0250,00009-3073-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,63.84,29.48,105,,,,,,00143-1172-01 - captopril 25 mg Tab [REEV],,0250,00143-1172-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,237.92,40.24,406.9,,,,,,00121-0595-15 - citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 15 mL [REEV],,0250,00121-0595-15,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,10.32,4.29,27.04,,,,,,68084-0672-01 - ALPRAZolam 0.5 mg Tab [REEV],,0250,68084-0672-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,74.48,6.15,4344.87,,,,,,00603-0841-54 - acetaminophen 160 mg/5 mL Oral Susp [REEV],,0250,00603-0841-54,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",296.7,222.53,222.53,180.39,24.86,180.39,,,,,,00093-8675-78 - amoxicillin-clavulanate 600 mg-42.9 mg/5 mL Oral Liq dose [REEV],,0250,00093-8675-78,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,50.95,19.15,448.97,,,,,,00517-2340-25 - iron sucrose 20 mg/mL IV Sol (PHS) [REEV],J1756,0250,00517-2340-25,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,271.53,28.6,1161.38,,,,,,00409-2267-20 - labetalol 100.,,0250,00409-2267-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,118.07,16.26,2475.42,,,,,,51079-0141-20 - chlordiazePOXIDE 25 mg Cap [REEV],,0250,51079-0141-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,271.53,68.61,524.17,,,,,,00338-0017-03 - Dextrose 5% in Water IV Sol 500 mL [REEV],,0250,00338-0017-03,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,113.47,20.72,3197.1,,,,,,13533-0634-02 - tetanus immune globulin 250 units IM Sol 1 EA [REEV],J1670,0250,13533-0634-02,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,47.71,34.19,143.78,,,,,,00904-3865-75 - sodium chloride Nasal 0.65% Spry [REEV],,0250,00904-3865-75,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,95.33,4.51,1156.79,,,,,,70030-0149-65 - ichthammol topical 20% Ointment,,0250,70030-0149-65,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,121.36,29.4,2785.69,,,,,,50633-0110-12 - Crotalidae polyvalent - Pow (PHS) [REEV],J0840,0250,50633-0110-12,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,48.28,12.56,48.28,,,,,,49281-0820-10 - tetanus toxoid IM Susp [REEV],,0250,49281-0820-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,24.14,10.24,44.01,,,,,,63029-8504-01 - benzocaine Top 20% Spry [REEV],,0250,63029-8504-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,29.55,13.42,41.31,,,,,,00004-0822-05 - oseltamivir 6 mg/mL Pow (bottle) [REEV],,0250,00004-0822-05,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,136.8,40.84,136.8,,,,,,00054-2527-25 - lithium 300 mg Cap [REEV],,0250,00054-2527-25,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,50.95,23.51,98.36,,,,,,00338-0409-03 - lidocaine 0.4%-D5W Inj Sol 500 mL [REEV],,0250,00338-0409-03,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,224.11,140.59,428.4,,,,,,25021-0608-20 - propofol 10 mg/mL 20 mL IV Emul [REEV],J2704,0250,25021-0608-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,00555-1009-16 - cloNIDine 0.1 mg/24 hr Transderm ER Film [REEV],,0250,00555-1009-16,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,234.02,61.48,2109.82,,,,,,00781-5180-92 - levothyroxine 25 mcg (0.025 mg) Tab [REEV],,0250,00781-5180-92,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,346.62,50,3116.59,,,,,,00409-9157-01 - phytonadione 1 mg/0.5 mL Inj Sol [REEV],J3430,0250,00409-9157-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,569.15,62.92,1098.7,,,,,,00904-6522-61 - senna 8.6 mg Tab [REEV],,0250,00904-6522-61,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,90.29,2.42,250.2,,,,,,68084-0230-01 - sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [REEV],,0250,68084-0230-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,280.7,5.83,3301.98,,,,,,"39822-0205-01 - pancrelipase DR 5000 units-17,000 units-27,000 units Cap [REEV]",,0250,39822-0205-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,30.7,0.68,2868.2,,,,,,00904-6126-61 - terazosin 1 mg Cap [REEV],,0250,00904-6126-61,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,33.74,13.53,65.14,,,,,,51079-0299-20 - cloNIDine 0.1 mg Tab [REEV],,0250,51079-0299-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,15.35,2.1,2819.66,,,,,,51079-0981-20 - lisinopril 5 mg Tab [REEV],,0250,51079-0981-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J1956,Levofloxacin injection [HCPCS J1956],12.5,9.38,9.38,15.2,5.5,16.47,,,,,,68084-0536-01 - clopidogrel 75 mg Tab [REEV],,0250,68084-0536-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,15.35,0.73,808.23,,,,,,51079-0024-20 - metolazone 5 mg Tab [REEV],,0250,51079-0024-20,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,15.35,7.08,29.34,,,,,,00069-2587-10 - vancomycin 500 mg IV Inj [REEV],J3370,0250,00069-2587-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,30.4,7.8,30.4,,,,,,00056-0172-75 - warfarin 5 mg Tab [REEV],,0250,00056-0172-75,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,30.39,3.15,30.39,,,,,,68084-0843-01 - carvedilol 3.125 mg Tab [REEV],,0250,68084-0843-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,15.2,0.95,3583.7,,,,,,63323-0413-10 - neostigmine 0.5 mg/mL [REEV],J2710,0250,63323-0413-10,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,15.35,1.72,16.28,,,,,,00409-1273-32 - diazepam 5 mg/mL Inj Sol [REEV],J3360,0250,00409-1273-32,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,15.35,5.5,19.14,,,,,,00056-0169-75 - warfarin 1 mg Tab [REEV],,0250,00056-0169-75,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,12.28,1.76,23.48,,,,,,68084-0119-01 - mirtazapine 15 mg Tab [REEV],,0250,68084-0119-01,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,21.49,0.02,4433.9,,,,,,50383-0779-31 - lactulose 10 g/15 mL Oral Syrup [REEV],,0250,50383-0779-31,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,330,3.97,330,,,,,,00409-1162-02 - bupivacaine 0.5% PF Inj Sol 30 mL [REEV],J2150,0250,00409-1162-02,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],575.5,431.63,431.63,119.9,119.9,119.9,,,,,,00121-1550-00 - codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 10 mL [REEV],,0250,00121-1550-00,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,93.5,52.38,170.1,,,,,,00641-6135-25 - prochlorperazine 5 mg/mL Inj Sol [REEV],J0780,0250,00641-6135-25,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,144.65,81.71,178.67,,,,,,51079-0058-20 - chlorthalidone 25 mg Tab [REEV],,0250,51079-0058-20,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,122.64,59.92,194.57,,,,,,68084-0216-01 - metroNIDAZOLE 250 mg Tab [REEV],,0250,68084-0216-01,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,168.85,95.05,222.03,,,,,,51079-0597-20 - cetirizine 10 mg Tab [REEV],,0250,51079-0597-20,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,248.05,120.14,248.05,,,,,,51079-0131-20 - amitriptyline 10 mg Tab [REEV],,0250,51079-0131-20,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,51.15,31.68,51.15,,,,,,66647-2010-73 - HYDROmorphone 6MG/30ML SYRINGE PCA [REEV],J1170,0250,66647-2010-73,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],257,192.75,192.75,130.9,99.96,130.9,,,,,,50383-0062-11 - dextromethorphan-guaifenesin 20 mg-200 mg/10 mL UD [REEV],,0250,50383-0062-11,,,
UMR - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,93.5,59.99,274.04,,,,,,00641-6044-25 - LORazepam 2 mg/mL Inj Sol [REEV],J2060,0250,00641-6044-25,,,
UMR NRECA - Commercial-PPO,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,767.87,73.48,1221.85,,,,,,51079-0107-20 - amitriptyline 25 mg Tab [REEV],,0250,51079-0107-20,,,
UMR NRECA - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,225.03,61.48,2109.82,,,,,,68084-0207-01 - spironolactone 50 mg Tab [REEV],,0250,68084-0207-01,,,
"ALLISON CRANE & RIGGING, INC. - Commercial-Indemnity",,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,72.8,13.55,72.8,,,,,,68084-0859-01 - levETIRAcetam 250 mg Tab [REEV],,0250,68084-0859-01,,,
UMR SUTTERSELECT - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,51079-0779-20 - acetaminophen-HYDROcodone 325 mg-10 mg Tab [REEV],,0250,51079-0779-20,,,
UMR USNAS - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.77,2.44,580.94,,,,,,50268-0152-15 - cephalexin 500 mg Cap [REEV],,0250,50268-0152-15,,,
UMR USNAS - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,68094-0001-62 - morphine 10 mg/5 mL Oral Sol [REEV],,0250,68094-0001-62,,,
UMR USNAS - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.63,6,88.2,,,,,,51079-0073-20 - furosemide 40 mg Tab [REEV],,0250,51079-0073-20,,,
UMR USNAS - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,121.36,29.4,2785.69,,,,,,51079-0991-20 - traMADol 50 mg Tab - 6pk [REEV],,0250,51079-0991-20,,,
UMR USNAS - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,234.02,61.48,2109.82,,,,,,"00121-4810-00 - nystatin 100,000 units/mL Oral Susp [REEV]",,0250,00121-4810-00,,,
UMR USNAS - Commercial-PPO,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,17.67,5.49,347.63,,,,,,00703-4502-84 - metoclopramide 5 mg/mL Inj Sol [REEV],J2765,0250,00703-4502-84,,,
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],162.8,122.1,122.1,68.97,64.49,171,,,,,,66689-0047-30 - potassium chloride 20 mEq/15 mL Oral Liq [REEV],,0250,66689-0047-30,,,
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,57250,Herniated rectum repair into vaginal wall repair [HCPCS 57250],2917.3,2187.98,2187.98,301.2,301.2,301.2,,,,,,ANESTHESIA PRO FEE CHARGE,,,,,,
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,58552,Vaginal hysterectomy including removal of tubes and/or ovaries with endoscope (uterus removal of uterus 250 grams or less) [HCPCS 58552],4284.4,3213.3,3213.3,953.61,953.61,953.61,,,,,,99135 ANES QUALIFYING CIRCUMSTANCES FOR ANESTHESIA ProFee,99135,,,,,
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,69.82,52.38,170.1,,,,,,Fetal Non-Stress Test,59025,0729,,339.6,254.7,254.7
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,94.91,52.53,206.9,,,,,,RT Aerosol Initial CHARGE,94640,0410,,83.8,62.85,62.85
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,0,95.05,222.03,,,,,,RT Ventilator Services Subsequent CHARGE,94003,0410,,758.6,568.95,568.95
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,69.53,39.55,134.08,,,,,,RT Arterial Puncture CHARGE,36600,0410,,293.6,220.2,220.2
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,RT Cardiopulmonary Resuscitation CHARGE,92950,0480,,171,128.25,128.25
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,0,45.48,91.29,,,,,,RT Oxygen Hours CHARGE,,0270,,27.7,20.775,20.775
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,126.93,114.76,176.55,,,,,,RT Oxyhood Setup CHARGE,,0270,,27.7,20.775,20.775
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,0,59.99,274.04,,,,,,"RT POX, Multiple Determination CHARGE",94761,0460,,112.5,84.375,84.375
UNITED AMERICAN INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,33.41,33.41,326.4,,,,,,"RT POX, Single Determination CHARGE",94760,0460,,56.3,42.225,42.225
UNITED HEALTHCAR - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,RT Pre & Post Spiro CHARGE,94060,0460,,308.7,231.525,231.525
UNITED HEALTHCAR - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,RT Stress Test Myoview CHARGE,93017,0482,,469.7,352.275,352.275
UNITED HEALTHCAR - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,RT Holter Hook Up CHARGE,93225,0731,,296.7,222.525,222.525
UNITED HEALTHCAR - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,ROOM/BED: Outpatient in a Bed,,0761,,112.5,84.375,84.375
UNITED HEALTHCAR - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,ROOM/BED: Swingbed,,0110,,581.1,435.825,435.825
UNITED HEALTHCAR - Commercial-PPO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,59025 NON STRESS TEST CHARGE,59025,0729,,339.6,254.7,254.7
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,257.82,15.26,797.02,,,,,,ROOM/BED: Private,,0110,,581.1,435.825,435.825
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,301,Peripheral vascular disorders without complications,679.4,509.55,509.55,92.2,92.2,1519.88,,,,,,ROOM/BED: Bill Only,G0378,0762,,24.3,18.225,18.225
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,305,Hypertension without major complications,504.1,378.08,378.08,73.59,56.14,1006,,,,,,"90621 Meningococcal vaccine, Serogroup B, 2 dose schedule, for IM use",90621,0521,,,,
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,236.65,114.13,1811.75,,,,,,"90621 VFC Meningococcal vaccine, Serogroup B, 2 dose schedule, for IM use",90621,0521,,,,
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,566,Other musculoskeletal system & connective tissue diagnoses without complications,225,168.75,168.75,60.22,60.22,819.69,,,,,,"90714 VFC Tenivac - Tetanus and diphtheria toxoids (Td), over 18",90714,0521,,,,
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,638,Diabetes with complications,9974.78,7481.09,7481.09,121.02,121.02,4314.45,,,,,,"90732 VFC Pneumococcal polysaccharide vaccine, 23-valent, for subcutaneous or intramuscular use",90732,0521,,,,
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,81.11,16.31,81.11,,,,,,"J1815 Injection, insulin, per 5 units",J1815,0521,,,,
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,5253.83,3940.37,3940.37,18.72,13.56,1256.28,,,,,,CT Chest/Abd/Pelvis w/ + w/o Contrast,74178,0352,,"4,712.1",3534.075,3534.075
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,696,Kidney & urinary tract signs & symptoms without major complications,108.1,81.08,81.08,76.31,14.28,326.3,,,,,,CT Chest/Abd/Pelvis w/ Contrast,74177,0352,,"3,922.7",2942.025,2942.025
UNITED HEALTHCAR - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,CT Chest/Abd/Pelvis w/o Contrast,74176,0352,,"3,693.4",2770.05,2770.05
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,2.14,2.09,3.53,,,,,,CT Angio Head/Neck,70496,0352,,"1,345.1",1008.825,1008.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,45.8,4.51,1156.79,,,,,,MRA Spine Cervical w/ Contrast,72159,0610,,"1,415.7",1061.775,1061.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],230.5,172.88,172.88,89.65,80.15,262.94,,,,,,MRA Spine Cervical w/o Contrast,72159,0610,,"1,415.7",1061.775,1061.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,131.45,131.45,310.8,,,,,,MRA Spine Lumbar w/ Contrast,72159,0610,,"1,415.7",1061.775,1061.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,53.91,35.11,337.46,,,,,,MRA Spine Lumbar w/o Contrast,72159,0610,,"1,415.7",1061.775,1061.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,86.35,70.45,319.43,,,,,,MRA Spine Thoracic w/ Contrast,72159,0610,,"1,415.7",1061.775,1061.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,107.28,315.01,,,,,,MRA Spine Thoracic w/o Contrast,72159,0610,,"1,415.7",1061.775,1061.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],65.1,48.83,48.83,68.4,68.4,240.69,,,,,,US Thyroid,76536,0402,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Institutional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],1.25,0.94,0.94,1.41,1.41,29.34,,,,,,XR TMJ Open and Closed Left,70328,0320,,207.3,155.475,155.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,56420,Female genital gland abscess incision and drainage [HCPCS 56420],533.5,400.13,400.13,181.5,181.5,181.5,,,,,,XR TMJ Open and Closed Right,70328,0320,,207.3,155.475,155.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.14,2.07,19.9,,,,,,"J0690 Injection, cefazolin sodium, 500 mg",J0690,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.3,5.3,61.31,,,,,,CT Sinus w/ + w/o Contrast,70488,0351,,"1,572.2",1179.15,1179.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,14,12.82,82,,,,,,CT Sinus w/ Contrast,70487,0351,,"1,319.8",989.85,989.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,"J7611 Albuterol, inhalation solution, fda-approved final product, non-compounded, administered throu",J7611,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,55.63,36.98,63.97,,,,,,US Axilla Left,76882,0402,,309.9,232.425,232.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,169.89,134.02,193.88,,,,,,US Axilla Right,76882,0402,,309.9,232.425,232.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,US OB < 14 Weeks Multi,76802,0402,,125.7,94.275,94.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,89.65,45.56,141.93,,,,,,US OB < 14 Weeks Single,76801,0402,,653.9,490.425,490.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,131.45,91.42,145.6,,,,,,US Pelvic Ltd,76857,0402,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,XR Chest 1 View,71045,0320,,250.4,187.8,187.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,US Spleen,76705,0402,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,US Echocardiogram 2D + M-Mode,93306,0480,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,175.45,147.2,226.48,,,,,,00386-0001-03 - ethyl chloride Top 100% Spry (PHS) [REEV],,0250,00386-0001-03,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,65.1,65.1,68.4,,,,,,00409-1754-10 - magnesium sulfate 50% Inj Sol 10 mL [REEV],J3475,0250,00409-1754-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,68.4,55.34,245.75,,,,,,00409-4888-10 - sodium chloride 0.9% Inj Sol 10 mL [REEV],,0250,00409-4888-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,MRI LE Joint w/ + w/o Contrast Lt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,J1030,Methylprednisolone 40 mg inj [HCPCS J1030],26.3,19.73,19.73,5.63,4.94,5.92,,,,,,MRI LE Joint w/ + w/o Contrast Rt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,MRI LE Joint w/ Contrast Lt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.23,1.1,17.76,,,,,,MRI LE Joint w/ Contrast Rt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,440,Disorders of pancreas except malignancy without complications,8042.43,6031.82,6031.82,13236.43,2986.27,13236.43,,,,,,MRI LE Joint w/o Contrast Lt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,11424,"Removal of non-cancerous skin lesion of scalp, neck, hands, feet, or genitalia (3.1 to 4.0 cm) [HCPCS 11424]",5652.97,4239.73,4239.73,2601.57,2601.57,2601.57,,,,,,MRI LE Joint w/o Contrast Rt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,11623,"Removal of cancerous skin lesion of scalp, neck, hands, feet, or genitalia (2.1 to 3.0 cm) [HCPCS 11623]",8546.7,6410.03,6410.03,1272,1272,1272,,,,,,MRI UE Joint w/ + w/o Contrast Lt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,76.75,55,125,,,,,,MRI UE Joint w/ + w/o Contrast Rt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,12013,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.6 to 5.0 cm) [HCPCS 12013]",469.98,352.49,352.49,76.75,55,111.73,,,,,,MRI UE Joint w/ Contrast Lt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.77,2.44,580.94,,,,,,MRI UE Joint w/ Contrast Rt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],4605.38,3454.04,3454.04,1272,15.34,2509.37,,,,,,MRI UE Joint w/o Contrast Lt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],4243.39,3182.54,3182.54,1272,246.83,3309.99,,,,,,MRI UE Joint w/o Contrast Rt,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,113.33,32.67,218.78,,,,,,US Gallbladder,76705,0402,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,919.34,137.3,1347.57,,,,,,US Guided Needle Placement,76942,0402,,653.9,490.425,490.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,152.24,20.71,250.4,,,,,,MRI Fetal w/ or w/o Maternal Pelvis,74712,0610,,522.6,391.95,391.95
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,153.44,109.96,166.13,,,,,,MRI Orbits w/ + w/o Contrast,70543,0610,,"1,974.7",1481.025,1481.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,773.64,137.3,1124.55,,,,,,MRI Orbits w/o Contrast,70540,0610,,"1,046.4",784.8,784.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,762.04,166.13,1107.72,,,,,,US Aorta Complete,76770,0610,,653.9,490.425,490.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,131.52,94.25,222.4,,,,,,US Aorta Limited,76775,0402,,580,435,435
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,131.52,33.08,182.07,,,,,,US Guided Amniocentesis,76946,0402,,476.3,357.225,357.225
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,136.8,57.76,225,,,,,,MRI Breast w/ + w/o Contrast Left.,77048,0610,,"2,000",1500,1500
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,136.8,94.25,214.2,,,,,,MRI Breast w/ + w/o Contrast Right.,77048,0610,,"2,000",1500,1500
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],225,168.75,168.75,136.8,27.06,225,,,,,,MRI Breast w/ Contrast Left.,77048,0610,,"2,000",1500,1500
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,136.8,56.37,178.99,,,,,,MRI Breast w/ Contrast Right.,77048,0610,,"2,000",1500,1500
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1468.01,561.23,2500,,,,,,MRI Breast w/o Contrast Left.,77046,0610,,"2,000",1500,1500
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,284.97,110.94,589.78,,,,,,MRI Breast w/o Contrast Right.,77046,0610,,"2,000",1500,1500
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,256.09,166.13,421.2,,,,,,US Biliary Tract,76705,0402,,561.3,420.975,420.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,408.27,166.13,529.81,,,,,,US Breast Complete Bilat,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,78.65,23.61,157.86,,,,,,US Breast Complete Bilat.,76641,0402,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,174.07,89.59,349.41,,,,,,US Breast Limited Bilat.,76642,0402,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,97.89,8.49,161,,,,,,US Echocardiogram Limited,93308,0480,,459.8,344.85,344.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,XR Abdomen 1 View,74018,0320,,225,168.75,168.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,87.07,11.25,148.9,,,,,,XR Abdomen 2 Views,74019,0320,,225,168.75,168.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,280.9,48.41,364.52,,,,,,XR Abdomen 3+ Views,74021,0320,,79.4,59.55,59.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,181,14.4,297.7,,,,,,XR Chest 3 Views,71047,0320,,270.2,202.65,202.65
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,189.09,63.16,518.42,,,,,,XR Finger(s) 2+ Views Left,73140,0320,,225,168.75,168.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,46.33,2.66,76.2,,,,,,XR Finger(s) 2+ Views Right,73140,0320,,225,168.75,168.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,30.95,1.89,53,,,,,,XR Fluoroscopy Under 1 Hour EO,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,47.71,6.2,81.6,,,,,,XR Mastoids < 3 Views Left,70120,0320,,243.7,182.775,182.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,15.47,2.31,20.91,,,,,,XR Mastoids < 3 Views Right,70120,0320,,243.7,182.775,182.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,58.37,5.44,96,,,,,,XR Toe(s) 2+ Views Right,73660,0320,,225,168.75,168.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],118.1,88.58,88.58,71.8,4.22,71.8,,,,,,US Pancreas,76705,0402,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,169.59,30.08,290.1,,,,,,Unattended Electrical Therapy Charge,97014,0420,,62.9,47.175,47.175
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,39.58,5.81,65.1,,,,,,Attended E-Stim Charges,97032,0420,,96,72,72
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,56.73,4.35,81.23,,,,,,Iontophoresis Charges,97033,0420,,101.5,76.125,76.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],480.7,360.53,360.53,140.54,28.4,180.6,,,,,,Manual Therapy Charge Units,97140,0420,,83.8,62.85,62.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,69.01,11.45,112.4,,,,,,Massage Charge Units,97124,0420,,90.4,67.8,67.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.34,2.66,8.7,,,,,,Gait Training Charges,97116,0420,,101.5,76.125,76.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82977,Lab analysis to measure the glutamyltransferase (liver enzyme) level [HCPCS 82977],65.1,48.83,48.83,39.58,11.93,52.08,,,,,,Therapeutic Activities Charge,97530,0420,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,128.94,16.1,220.5,,,,,,Orthotic Mgmt and Training Charges,97760,0420,,171,128.25,128.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",399.1,299.33,299.33,104.44,18.83,178.6,,,,,,Prosthetic Training Charges,97761,0420,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,70.47,8.16,104.31,,,,,,Wheelchair Management Charges,97542,0420,,75,56.25,56.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83525,Lab analysis to measure the amount of total insulin [HCPCS 83525],147.8,110.85,110.85,89.86,18.95,89.86,,,,,,Neuromuscular Reeducation Charges,97112,0420,,122.5,91.875,91.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,118.01,9.72,190.22,,,,,,Ultrasound Charges,97035,0420,,79.4,59.55,59.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,90.93,5.07,94.54,,,,,,Paraffin Bath Charge,97018,0420,,72.8,54.6,54.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,61.89,5,105.9,,,,,,Mechanical Traction Charge,97012,0420,,91.6,68.7,68.7
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,171.64,32.98,268.8,,,,,,Therapeutic Exercise Charges,97110,0420,,112.5,84.375,84.375
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,118.01,41.96,133.85,,,,,,Other Thermal Charge,97010,0420,,48.6,36.45,36.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,32.22,4.75,40.9,,,,,,PT Work Hardening Charge,97545,0420,,421.2,315.9,315.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,108.31,19.44,112.66,,,,,,Work Hardening Additional Hours Charge,97546,0420,,66.2,49.65,49.65
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84154,Lab analysis to measure the amount of free PSA (prostate specific antigen) in serum specimen [HCPCS 84154],222.7,167.03,167.03,135.4,93.32,135.4,,,,,,Selective Debridement Charge,97597,0420,,225,168.75,168.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,146.16,25.9,240.4,,,,,,Non-Selective Debridement Charge,97602,0420,,113.7,85.275,85.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,79.1,7.58,134.6,,,,,,ADL Training Charge,97535,0420,,101.5,76.125,76.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,79.33,14.11,134.34,,,,,,Functional Capacity Eval Charge,97750,0420,,147.8,110.85,110.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,85.85,9.87,141.2,,,,,,Phonophoresis Charge,97039,0420,,59.6,44.7,44.7
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,32.22,4.54,50.4,,,,,,Selective Debridement Addition Charge,97598,0420,,54.1,40.575,40.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,36.1,7.65,55.26,,,,,,Myofacial Release Charges,97140,0420,,83.8,62.85,62.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.63,6,88.2,,,,,,PT Canalith Repositioning Charge,95992,0420,,205.1,153.825,153.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,22.8,5.43,37.5,,,,,,PT Contrast Bath Charges,97034,0420,,72.8,54.6,54.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,116.68,8.55,182.7,,,,,,PT Physical Performance Test Charges,97750,0420,,147.8,110.85,110.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,42.32,3.6,69.6,,,,,,"PT Self Care, Home Management Charges",97535,0420,,101.5,76.125,76.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,25.79,3.56,42,,,,,,PT Sensory Integration Charges,97533,0420,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,41.53,2.7,54.33,,,,,,PT Wound VAC <50 Charge,97605,0420,,164.4,123.3,123.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,42.32,6.03,69.6,,,,,,PT Wound VAC >50 Charge,97606,0420,,302.1,226.575,226.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,73.75,14.79,121.3,,,,,,PT Skills and Agility Charge,97750,0420,,147.8,110.85,110.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,37.57,4.34,61.8,,,,,,PT Muscle Testing (w/Hands) Charge,95832,0420,,137.9,103.425,103.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,73.75,11.52,121.3,,,,,,PT Muscle Testing Exl. Hands Charge,95831,0420,,140.1,105.075,105.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,54.83,16.62,74.01,,,,,,PT ROM Measurements and Report Charges,95851,0420,,122.5,91.875,91.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,60.37,7.24,496.86,,,,,,PT ROm Measurement and Hand Time Charge,95852,0420,,69.6,52.2,52.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,61.04,6.79,100.4,,,,,,PT Low Complex Units,97161,0420,,365,273.75,273.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,41.59,5.57,65.1,,,,,,PT Moderate Complex Units,97162,0420,,365,273.75,273.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,63.18,2.84,108.1,,,,,,PT High Complex Units,97163,0420,,365,273.75,273.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,15.08,6.8,52.43,,,,,,PT ReEval Units,97164,0420,,247,185.25,185.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,104.58,7.27,172,,,,,,PT Cognitive Function Charge,,0420,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,94.54,8.17,155.5,,,,,,PT Orthotic Mgmt/Train Establish Charge,97763,0420,,207.3,155.475,155.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,67.06,37.79,110.3,,,,,,PT Burn Dress/Debridement Small Charge,16020,0420,,315.4,236.55,236.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,94.54,29.48,155.5,,,,,,US Liver (Hepatic),76705,0402,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,94.54,29.48,155.5,,,,,,US OB Detailed Complete First Gest,76811,0402,,785,588.75,588.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,10.76,4.29,35.67,,,,,,96374 OP INJ IV PUSH INITIAL CHARGE,96374,0260,,316.5,237.375,237.375
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,100.56,45.82,378.9,,,,,,"94060 SPIROMETRY, PRE & POST Charge",94060,0460,,308.7,231.525,231.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,63.84,29.48,105,,,,,,Acetaminophen Level FSI,80329,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,0,40.24,406.9,,,,,,Albumin FSI,82040,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,19.34,4.29,27.04,,,,,,Alkaline Phosphatase FSI,84075,0300,,168.8,126.6,126.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,20.12,13.86,24.19,,,,,,ALT (SGPT) FSI,84460,0300,,65.1,48.825,48.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,20.12,20.12,77.89,,,,,,Ammonia FSI,82140,0300,,137.9,103.425,103.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,74.48,6.15,4344.87,,,,,,Amylase FSI,82150,0300,,96,72,72
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,94060,Amount and speed of breathed air measurement and graphic recording before and after medication administration [HCPCS 94060],308.7,231.53,231.53,180.52,20,362.32,,,,,,Antibody Screen FSI,86850,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,50.95,19.15,448.97,,,,,,AST (SGOT) FSI,84450,0300,,65.1,48.825,48.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,271.53,28.6,1161.38,,,,,,Basic Metabolic Panel (BMP) FSI,80048,0300,,161,120.75,120.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,46.94,16.26,2475.42,,,,,,"Bilirubin Neonatal, Total/Direct FSI",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,215.84,68.61,524.17,,,,,,"Bilirubin, Neonatal Total Biliscreen FSI",,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,45.8,4.51,1156.79,,,,,,"Bilirubin, Total FSI",82247,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,116.72,29.4,2785.69,,,,,,Brain Natriuretic Peptide BNP FSI,83880,0300,,282.3,211.725,211.725
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,23.21,12.56,48.28,,,,,,BUN FSI,84520,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,76.75,2.2,117.5,,,,,,Calcium FSI,82310,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,143.12,39.1,434.06,,,,,,CBC Complete Blood Count w/ Diff FSI,85025,0300,,88.2,66.15,66.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,225.03,61.48,2109.82,,,,,,Cell Count and Diff Fluid FSI,89051,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,346.62,50,3116.59,,,,,,Cholesterol FSI,82465,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,G0328,Fecal blood scrn immunoassay [HCPCS G0328],48.8,36.6,36.6,28.49,20.42,48.31,,,,,,CK (CPK) FSI,82550,0300,,65.1,48.825,48.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,6.75,3.22,2266.54,,,,,,Comprehensive Metabolic Panel (CMP) FSI,80053,0300,,246,184.5,184.5
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,7.6,5.5,14.67,,,,,,Creatinine FSI,82565,0300,,49.7,37.275,37.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,6.65,0.68,2868.2,,,,,,Electrolytes FSI,80051,0300,,83.8,62.85,62.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,1.52,0.11,332.88,,,,,,ESR (Westergren) FSI,85652,0300,,68.3,51.225,51.225
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,15.35,2.1,2819.66,,,,,,Ferritin FSI,82728,0300,,118.1,88.575,88.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,15.35,0.73,808.23,,,,,,Free T4 FSI,84439,0300,,130.1,97.575,97.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,15.35,7.08,29.34,,,,,,GGTP (GGT) FSI,82977,0300,,65.1,48.825,48.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,7.6,5.5,14.67,,,,,,Glucose 1 Hour Post 50 Gram Glucola FSI,82947,0300,,79.4,59.55,59.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.6,0.95,3583.7,,,,,,Glucose FSI,82947,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,5.07,1.72,16.28,,,,,,Hemoglobin A1C and EAG FSI,83036,0300,,115.9,86.925,86.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.76,0.55,29.34,,,,,,Hemoglobin and Hematocrit (HH) FSI,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,3.92,1.29,348.28,,,,,,Hemoglobin Electrophoresis FSI,85018,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,21.28,0.02,4433.9,,,,,,Hepatic Function Panel FSI,80076,0300,,185.3,138.975,138.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J7510,Prednisolone oral per 5 mg [HCPCS J7510],10.36,7.77,7.77,6.3,2.49,8.81,,,,,,"Herpes Simplex HSV 1,2 IgG, IgM FSI",,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Institutional,Outpatient,11623,"Removal of cancerous skin lesion of scalp, neck, hands, feet, or genitalia (2.1 to 3.0 cm) [HCPCS 11623]",8546.7,6410.03,6410.03,1272,1272,1272,,,,,,"Iron Profile, Includes TIBC, Percent Saturation FSI",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],4605.38,3454.04,3454.04,1272,15.34,2509.37,,,,,,LD (LDH) FSI,83615,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],4243.39,3182.54,3182.54,1272,246.83,3309.99,,,,,,Lipase FSI,83690,0300,,105.9,79.425,79.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Institutional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],310.8,233.1,233.1,326.4,130.46,326.4,,,,,,Lipid Profile FSI,80061,0300,,148.9,111.675,111.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Institutional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],162.8,122.1,122.1,171,64.49,171,,,,,,Magnesium FSI,83735,0300,,72.8,54.6,54.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Institutional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",314,235.5,235.5,329.7,55.67,329.7,,,,,,"Occult Blood, Fecal, ICT FSI",82274,0300,,48.8,36.6,36.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Professional,Outpatient,300,Anesthesia provided during esophagus and neck procedure [HCPCS 00300],139,104.25,104.25,7.04,6.45,46.89,,,,,,Phenytoin FSI,80185,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,5.51,1.64,80.91,,,,,,Phosphorus FSI,84100,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Professional,Outpatient,11424,"Removal of non-cancerous skin lesion of scalp, neck, hands, feet, or genitalia (3.1 to 4.0 cm) [HCPCS 11424]",1250.3,937.73,937.73,225.5,225.5,225.5,,,,,,Potassium FSI,84132,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,"PSA, Total FSI",84153,0300,,315.4,236.55,236.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,138.6,131.45,310.8,,,,,,PTT FSI,85730,0300,,69.6,52.2,52.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,Renal Function Panel FSI,80069,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,131.45,91.42,145.6,,,,,,RH (D) Type FSI,86901,0300,,48.6,36.45,36.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,Salicylate FSI,80329,0300,,75,56.25,56.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,"Sperm, Post Vasectomy FSI",89300,0300,,56.3,42.225,42.225
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,"T4, Total FSI",84436,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.77,2.44,580.94,,,,,,Triglyceride FSI,84478,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,2489.5,180.22,3324.06,,,,,,TSH FSI,84443,0300,,135.7,101.775,101.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,Uric Acid FSI,84550,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,297.7,14.4,297.7,,,,,,Urinalysis Complete FSI,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,76.2,2.66,76.2,,,,,,"45005 Incision and drainage of submucosal abscess, rectum",,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,16.11,2.31,20.91,,,,,,REEV Power Injector Syringes,,0272,,39.1,29.325,29.325
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,59.04,4.35,81.23,,,,,,REEV 60 mL Syringes,,0272,,1.6,1.2,1.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,70.47,8.16,104.31,,,,,,REEV Transfer Set with Spike and Valve,,0270,,16.8,12.6,12.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,64.39,5,105.9,,,,,,REEV Extension Set with 8.5 Pinch Clamp,,0270,,12.5,9.375,9.375
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,79.1,7.58,134.6,,,,,,REEV Kit IV Prep,,0272,,3.5,2.625,2.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,82.51,14.11,134.34,,,,,,REEV Jelco IV Catheter 18g,,0272,,5.5,4.125,4.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,88.2,6,88.2,,,,,,REEV Jelco IV Catheter 20g,,0272,,5.5,4.125,4.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,60.37,7.24,496.86,,,,,,REEV Jelco IV Catheter 22g,,0272,,5.5,4.125,4.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,108.1,2.84,108.1,,,,,,REEV Suction Canister,,0272,,4.8,3.6,3.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,110.3,37.79,110.3,,,,,,REEV Yankeur,,0272,,1.4,1.05,1.05
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,157.5,45.82,378.9,,,,,,REEV Oxygen Tubing,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,446.6,28.6,1161.38,,,,,,RT Ventilator Services Initial CHARGE,94002,0410,,758.6,568.95,568.95
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,92.4,16.26,2475.42,,,,,,Unattended Electrical Therapy Charge,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,190.1,29.4,2785.69,,,,,,36430 BLOOD ADMINISTRATION CHARGE,36430,0391,,"1,179.7",884.775,884.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,24.14,12.56,48.28,,,,,,CT IAC w/ + w/o Contrast,70482,0351,,"1,572.2",1179.15,1179.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,366.5,61.48,2109.82,,,,,,CT IAC w/ Contrast,70481,0351,,"1,319.8",989.85,989.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,570.1,50,3116.59,,,,,,CT IAC w/o Contrast,70480,0351,,"1,156.6",867.45,867.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.6,0.95,3583.7,,,,,,00517-0720-01 - betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [REEV],J0702,0250,00517-0720-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,35,0.02,4433.9,,,,,,55150-0169-10 - bupivacaine 0.5% PF Inj Sol 10 mL [REEV],S0020,0250,55150-0169-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,107.1,40.84,136.8,,,,,,63323-0360-19 - calcium gluconate 100 mg/mL Inj Sol [REEV],J0610,0250,63323-0360-19,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,79.8,23.51,98.36,,,,,,00517-0031-25 - cyanocobalamin 1000 mcg/mL Inj Sol [REEV],J3420,0250,00517-0031-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,347.6,140.59,428.4,,,,,,23155-0166-41 - tranexamic acid 100 mg/mL Sol (REEV),,0250,23155-0166-41,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,114,70.45,319.43,,,,,,RBC unit 1 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,11982,Drug delivery implant removal [HCPCS 11982],7988.05,5991.04,5991.04,517.2,517.2,517.2,,,,,,RBC unit 10 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,58300,Intra-uterine device (IUD) placement for pregnancy prevention [HCPCS 58300],2076.5,1557.38,1557.38,112.2,112.2,112.2,,,,,,RBC unit 11 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,2.14,2.09,3.53,,,,,,RBC unit 12 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,49.61,6.2,81.6,,,,,,RBC unit 13 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,86580,Lab skin analysis for tuberculosis [HCPCS 86580],125,93.75,93.75,5.03,5.03,5.03,,,,,,RBC unit 14 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",92.7,69.53,69.53,5.3,5.3,236.82,,,,,,RBC unit 15 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,287,279.97,287,,,,,,RBC unit 16 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,47.67,4.51,1156.79,,,,,,RBC unit 17 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],230.5,172.88,172.88,89.65,80.15,262.94,,,,,,RBC unit 18 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],301.1,225.83,225.83,251.35,251.35,251.35,,,,,,RBC unit 2 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,53.91,35.11,337.46,,,,,,RBC unit 3 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,86.35,70.45,319.43,,,,,,RBC unit 4 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,107.28,315.01,,,,,,RBC unit 5 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,175.45,113,283.23,,,,,,RBC unit 6 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,65.1,65.1,240.69,,,,,,RBC unit 7 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,65.1,65.1,240.69,,,,,,RBC unit 8 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,3.8,0.68,2868.2,,,,,,RBC unit 9 FSI,P9016,0381,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,1.29,1.29,348.28,,,,,,ABO FSI,86900,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,11201,Skin tag removal (each additional 10 tags) [HCPCS 11201],46,34.5,34.5,24.2,24.2,90.3,,,,,,ABO Rh FSI,86900,0300,,110.3,82.725,82.725
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,11750,Nail removal [HCPCS 11750],686.9,515.18,515.18,268.96,268.96,268.96,,,,,,Cord ABORh FSI,86901,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,51701,Temporary bladder catheter insertion [HCPCS 51701],372.7,279.53,279.53,98.46,43.71,98.46,,,,,,Cord ABORh and Direct Coombs FSI,86901,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.14,2.07,19.9,,,,,,U 10 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.3,5.3,61.31,,,,,,U 11 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,14,12.82,82,,,,,,U 12 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,U 13 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,304.17,156.33,346.97,,,,,,U 14 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,20.95,15.77,25,,,,,,U 15 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,90707,"Measles, mumps, and rubella (German measles) vaccine for injection beneath skin [HCPCS 90707]",122.9,92.18,92.18,104.33,61.45,104.33,,,,,,U 16 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,55.63,36.98,63.97,,,,,,U 17 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,170.1,85.05,170.1,,,,,,U 18 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,169.89,134.02,193.88,,,,,,U 9 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,90746,"Hepatitis B vaccine injection into muscle (adult dosage, 3 dose schedule) [HCPCS 90746]",155.4,116.55,116.55,76.08,75.24,76.08,,,,,,U1 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,U2 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,89.65,45.56,141.93,,,,,,U3 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,131.45,91.42,145.6,,,,,,U4 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,200.2,140.39,202.54,,,,,,U5 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],281.2,210.9,210.9,251.35,185.38,251.35,,,,,,U6 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,0,8.98,23.86,,,,,,U7 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,U8 RBC Compatibility FSI,86920,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,U1 Cryo Compatibility FSI,P9012,0387,,661.5,496.125,496.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,U2 Cryo Compatibility FSI,P9012,0387,,661.5,496.125,496.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,175.45,147.2,226.48,,,,,,U3 Cryo Compatibility FSI,P9012,0387,,661.5,496.125,496.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,U4 Cryo Compatibility FSI,P9012,0387,,661.5,496.125,496.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,U5 Cryo Compatibility FSI,P9012,0387,,661.5,496.125,496.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,68.4,55.34,245.75,,,,,,Direct Coombs FSI,86880,0300,,75,56.25,56.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,65.1,65.1,245.75,,,,,,U1 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,68.4,68.4,245.75,,,,,,U2 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,U3 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,15.19,14.35,372.57,,,,,,U4 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,U5 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,J1030,Methylprednisolone 40 mg inj [HCPCS J1030],26.3,19.73,19.73,5.92,4.94,5.92,,,,,,U6 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0,0.08,6.58,,,,,,U7 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,U8 FFP Compatibility FSI,P9059,0383,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.23,1.1,17.76,,,,,,Transfusion Reaction Workup FSI,86900,0300,,774,580.5,580.5
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Clinic,Professional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],31.5,23.63,23.63,1.8,1.8,4.88,,,,,,U1 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,10441.66,7831.25,7831.25,5855,5855,5855,,,,,,U2 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,795,Normal Newborn,29.9,22.43,22.43,2285.79,36.01,2285.79,,,,,,U3 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,76.75,55,3102.09,,,,,,U4 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,10080,Tailbone cyst incision and drainage (simple procedure) [HCPCS 10080],5423.63,4067.72,4067.72,2307.41,2307.41,2307.41,,,,,,U5 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,1647.8,393.52,2894.06,,,,,,U6 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,11043,Skin and muscle removal (first 20 sq cm or less) [HCPCS 11043],2098.2,1573.65,1573.65,1275.71,837.32,1391.28,,,,,,U7 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,11045,Skin and tissue removal (each additional 20 sq cm) [HCPCS 11045],132.3,99.23,99.23,80.44,52.8,87.48,,,,,,U8 Platelet Compatibility FSI,P9019,0384,,"1,329.7",997.275,997.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,11402,"Removal of non-cancerous skin lesion of trunk, arms, or legs (1.1 to 2.0 cm) [HCPCS 11402]",5048.74,3786.56,3786.56,553.54,553.54,553.54,,,,,,Rhogam Workup FSI,86906,0300,,390.3,292.725,292.725
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,11404,"Removal of non-cancerous skin lesion of trunk, arms, or legs (3.1 to 4.0 cm) [HCPCS 11404]",7628.24,5721.18,5721.18,2399.17,2399.17,2399.17,,,,,,Therapeutic Phlebotomy FSI,99195,0300,,175.4,131.55,131.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,11442,"Removal of non-cancerous skin lesion of face, ears, eyelids, nose, lips, or mouth (1.1 to 2.0 cm) [HCPCS 11442]",5195.37,3896.53,3896.53,553.54,553.54,553.54,,,,,,Type and Screen FSI,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,76.75,55,125,,,,,,Weak D FSI,86885,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,12004,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (7.6 to 12.5 cm) [HCPCS 12004]",863.04,647.28,647.28,76,76,119.35,,,,,,Bill Only Call Back Fee,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,76,55,125,,,,,,Bill Only Stat Fee,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,17250,Chemical agent application to wound tissue [HCPCS 17250],709,531.75,531.75,414.57,205.89,468.8,,,,,,Bill Only Cryo Handling Fee,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,24605,Dislocated elbow treatment with anesthesia [HCPCS 24605],1253.7,940.28,940.28,125,125,125,,,,,,Bill Only Venipuncture,36415,0300,,21,15.75,15.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,31500,Breathing tube insertion into windpipe cartilage with endoscope (emergent) [HCPCS 31500],567.9,425.93,425.93,273.69,237.95,666.54,,,,,,Bill Only Pap Charge - No Ins.,,0310,,115.9,86.925,86.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.77,2.44,580.94,,,,,,Bill Only Cytology Charge - No Ins.,,0310,,70.6,52.95,52.95
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,717.26,494.34,1384.62,,,,,,Bill Only Tissue Charge - No Ins.,,0310,,263.6,197.7,197.7
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,36558,Tunneled central venous catheter insertion for infusion (5 years of age or older) [HCPCS 36558],7281,5460.75,5460.75,4426.85,4426.85,4426.85,,,,,,Bill Only ABG Kit,,0270,,5.6,4.2,4.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,36600,Collection of blood specimen from arterial puncture for diagnosis [HCPCS 36600],293.6,220.2,220.2,171.67,39.78,171.67,,,,,,Bill Only Arterial Puncture,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",3443.56,2582.67,2582.67,1202.14,1202.14,1861.53,,,,,,Bill Only On Call Fee After 5pm weekends and holidays,,0300,,468.7,351.525,351.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],11326.9,8495.18,8495.18,2696.69,2696.69,4250.36,,,,,,Bill Only Stat Charge - UBS,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],3522.49,2641.87,2641.87,1202.14,179.75,1202.14,,,,,,Bill Only Urinalysis w/o Micro FSI,81003,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],4605.38,3454.04,3454.04,553.55,15.34,2509.37,,,,,,Glucose Tolerance 2 Hr PP FSI,82950,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],4243.39,3182.54,3182.54,2214.15,246.83,3309.99,,,,,,Glucose Tolerance 2 Hr FSI,82951,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,182.83,119.94,617.26,,,,,,Glucose Tolerance 3 Hr FSI,82951,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,68.4,32.67,218.78,,,,,,"Acetone, Serum FSI",82010,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70140,Facial bones x-ray for injuries or lesions (less than 3 views) [HCPCS 70140],225,168.75,168.75,136.8,123.34,148.78,,,,,,Ethanol Level FSI,80320,0300,,86,64.5,64.5
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70150,Facial bones x-ray for injuries or lesions (minimum of 3 views) [HCPCS 70150],225,168.75,168.75,136.8,136.8,166.13,,,,,,Blood Gas Arterial FSI,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70360,Neck x-ray to examine soft tissue for any obstructions and/or foreign bodies within the throat or neck [HCPCS 70360],225,168.75,168.75,131.52,94.25,182.07,,,,,,"HCG Quantitative, Serum FSI",84702,0300,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,955.9,137.3,1347.57,,,,,,Bilirubin Unconjugated FSI,82248,0300,,118.1,88.575,88.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70490,"Neck CT scan of the soft tissue of the neck without contrast to examine injury, foreign bodies, or tumors [HCPCS 70490]",1156.6,867.45,867.45,703.21,166.13,703.21,,,,,,Bleeding Time FSI,85002,0300,,28.7,21.525,21.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70496,CTA scan of head blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70496],1345.1,1008.83,1008.83,817.82,563.64,889.41,,,,,,pH Blood FSI,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70498,CTA scan of neck blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70498],1345.1,1008.83,1008.83,817.82,294.63,889.41,,,,,,Carbon Dioxie (CO2) FSI,82374,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,152.24,20.71,250.4,,,,,,Cardiac Panel FSI,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,164.95,28.74,271.3,,,,,,Chloride Level FSI,82435,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,136.8,94.25,177.23,,,,,,CKMB and %MB FSI,82553,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,159.54,109.96,166.13,,,,,,Clinitest FSI,81002,0300,,18.8,14.1,14.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,804.38,137.3,1124.55,,,,,,CSF Cell Count FSI,89050,0300,,48.6,36.45,36.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,858.74,272.21,1200.54,,,,,,CSF Differential FSI,89051,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1412.4,1059.3,1059.3,817.82,272.21,898.39,,,,,,D-Dimer FSI,85379,0300,,191.9,143.925,143.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,136.8,4.45,148.78,,,,,,Digoxin Level FSI,80162,0300,,107,80.25,80.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72050,Spinal x-ray of upper spine (4 or 5 views) [HCPCS 72050],355,266.25,266.25,215.84,50.72,234.73,,,,,,Gentamycin Peak FSI,80170,0300,,107,80.25,80.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72080,Spinal x-ray of junction of middle and lower spine (2 views) [HCPCS 72080],121.3,90.98,90.98,73.75,68.69,123.34,,,,,,Gentamycin Trough FSI,80170,0300,,184.2,138.15,138.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,136.8,69.84,223.7,,,,,,Hemoglobin and Hematocrit - Dialysis (HH) FSI,85018,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,136.8,4.41,166.13,,,,,,H. Pylori Ab FSI,87339,0300,,83.8,62.85,62.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,792.35,166.13,1107.72,,,,,,Hematocrit FSI,85014,0300,,10,7.5,7.5
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72128,"Spinal CT scan of middle spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72128]",1323,992.25,992.25,804.38,804.38,804.38,,,,,,HIV 1/2 Screen FSI,86703,0300,,121.3,90.975,90.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,804.38,166.13,1309.77,,,,,,I-Stat Basic Metabolic Panel (BMP) FSI,80047,0300,,161,120.75,120.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,636.21,350.85,825.61,,,,,,I-Stat Hemoglobin and Hematocrit (HH) FSI,85014,0300,,44.1,33.075,33.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72200,X-ray of joints at hip bone and sacrum (less than 3 views) [HCPCS 72200],225,168.75,168.75,136.8,136.8,136.8,,,,,,Urinalysis Microscopic Automated FSI,81001,0300,,76.2,57.15,57.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72220,X-ray of sacrum and tailbone (minimum of 2 views) [HCPCS 72220],225,168.75,168.75,131.52,94.25,148.93,,,,,,Iron Level FSI,83540,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,136.8,94.25,222.4,,,,,,KOH Yeast FSI,87205,0300,,51.9,38.925,38.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,136.8,25.73,191.25,,,,,,Lactate FSI,83605,0300,,194.1,145.575,145.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",225,168.75,168.75,131.52,94.25,180,,,,,,.Manual Differential FSI,85007,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,136.8,24.39,148.78,,,,,,Rapid Mono Test FSI,86308,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,136.8,18.85,148.78,,,,,,"Occult Blood, Fecal, 2 Spec FSI",82274,0300,,48.8,36.6,36.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,136.8,33.08,182.07,,,,,,"Occult Blood, Fecal, 3 Spec FSI",82274,0300,,48.8,36.6,36.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,136.8,99,166.13,,,,,,"Occult Blood, Fecal, 4 Spec FSI",82274,0300,,48.8,36.6,36.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,136.8,30.08,220.5,,,,,,Phosphorus - Dialysis FSI,84100,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,136.8,94.25,191.25,,,,,,Platelet Count FSI,85049,0300,,32.1,24.075,24.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],1046.4,784.8,784.8,636.21,508.22,636.21,,,,,,Postassium - Dialysis FSI,84132,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,131.52,57.76,225,,,,,,Pregnancy Test Serum FSI,84703,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],225,168.75,168.75,136.8,35.41,222.75,,,,,,Pregnancy Test Urine FSI,81025,0300,,81.6,61.2,61.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,136.8,29.4,177.53,,,,,,PT/INR FSI,85610,0300,,69.6,52.2,52.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,136.8,94.25,214.2,,,,,,Rapid Flu Test FSI,87400,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,176.38,73.09,246.59,,,,,,Rapid Strep FSI,87430,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],225,168.75,168.75,136.8,27.06,225,,,,,,RBC Count FSI,85041,0300,,341.8,256.35,256.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,131.52,69.84,225,,,,,,.RBC Morphology FSI,85008,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,136.8,37.7,213.75,,,,,,RSV Antigen FSI,87420,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73720,"Imaging of leg by MRI without contrast, followed by contrast [HCPCS 73720]",1974.7,1481.03,1481.03,1200.62,1200.62,1200.62,,,,,,Sodium Level FSI,84295,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,225,90,225,,,,,,T3 Uptake FSI,84479,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1513.62,180.22,3324.06,,,,,,Theophylline FSI,80198,0300,,91.6,68.7,68.7
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1526.38,561.23,2500,,,,,,Thyroid Panel I FSI,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",4712.1,3534.08,3534.08,1909.12,561.23,2284.78,,,,,,Thyroid Panel II FSI,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,454.48,110.94,589.78,,,,,,I-cTNI iSTAT,84512,0300,,174.2,130.65,130.65
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,246.28,166.13,421.2,,,,,,Protein Total FSI,84155,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,196.44,62.12,274.64,,,,,,Troponin I FSI,84484,0300,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,397.57,166.13,529.3,,,,,,Urine Drug Screen FSI,80306,0300,,297.7,223.275,223.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,284.97,137.3,401.67,,,,,,Vancomycin Peak FSI,80202,0300,,158.8,119.1,119.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,382.34,107.93,965.26,,,,,,Vancomycin Trough FSI,80202,0300,,158.8,119.1,119.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,382.34,137.3,529.3,,,,,,WBC Count FSI,85048,0300,,28.7,21.525,21.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,454.48,92.55,635.38,,,,,,WBC w/ Differential FSI,85004,0300,,30.9,23.175,23.175
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,392.65,166.13,529.81,,,,,,Wet Prep FSI,87210,0300,,32.1,24.075,24.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,341.27,166.13,1065.48,,,,,,Glucose Tolerance 1 Hr (no fasting gluc) FSI,82951,0300,,83.8,62.85,62.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",468.7,351.53,351.53,284.97,166.13,311.42,,,,,,PT High Complex Units,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],309.9,232.43,232.43,32.89,22.66,204.92,,,,,,PT Biofeedback Units,90901,0420,,354,265.5,265.5
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,81.78,23.61,157.86,,,,,,"90700 DTaP, under 7 years, for IM use",90700,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,181,89.59,349.41,,,,,,"46500 Injection of sclerosing solution, hemorrhoids",46500,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80047,"Lab analysis to measure the amount of ionized calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80047]",161,120.75,120.75,94.13,13.95,94.13,,,,,,"90649 VFC HPV vaccine, quadrivalent, over 18",90649,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,97.89,8.49,161,,,,,,"90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use",90701,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,285.58,41.68,551.29,,,,,,"90703 Tetanus toxoid adsorbed, for intramuscular use",90703,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,"90712 Poliovirus vaccine, (any type[s]) (OPV), live, for oral use",90712,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,90.93,43.35,182.52,,,,,,"90712 VFC Poliovirus vaccine, (any type[s]) (OPV), live, for oral use",90712,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,90.53,11.25,148.9,,,,,,90718 Tetanus and diphtheria toxoids (Td) adsorbed when administered to individuals 7 years or older,90718,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],131.3,98.48,98.48,79.83,55,99.65,,,,,,"90478 Hepatitis B and Haemophilus influenzae type b vaccine (Hib-HepB), for intramuscular use",90748,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,270.16,48.41,364.52,,,,,,97169 Athletic Physical,97169,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,112.66,8.3,183.45,,,,,,99499 Employment Physical,99499,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],99.3,74.48,74.48,60.37,13.12,94.5,,,,,,"J2675 Injection, progesterone, per 50 mg",J2675,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80195,Lab analysis to measure the amount of sirolimus in blood specimen [HCPCS 80195],263.6,197.7,197.7,154.11,154.11,154.11,,,,,,"57150 Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, o",57150,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,181,14.4,297.7,,,,,,90473 VFC Immunization administration by intranasal or oral route; first vaccine,90473,0521,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,181.81,63.16,518.42,,,,,,PRMH Normal Saline 100ml,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,52.29,9.42,73.71,,,,,,PRMH Technetium with PYP,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,79.83,9.63,285.09,,,,,,00409-3414-01 - metoclopramide 5 mg/mL Inj Sol [REEV],J2765,0250,00409-3414-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80346,Lab analysis to measure the amount of benzodiazepines (1 to 12) in urine or blood specimen [HCPCS 80346],248.2,186.15,186.15,150.91,146.51,150.91,,,,,,00781-3059-95 - digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [REEV],J1160,0250,00781-3059-95,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,46.33,2.66,76.2,,,,,,54288-0103-10 - EPINEPHrine 1 mg/mL Inj Sol [REEV],J0171,0250,54288-0103-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,32.22,1.89,53,,,,,,00143-9506-10 - etomidate 2 mg/mL IV Sol [REEV],J3490,0250,00143-9506-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,49.61,6.2,81.6,,,,,,63323-0280-16 - furosemide 10 mg/mL 2 mL Inj Sol [REEV],J1940,0250,63323-0280-16,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82010,"Lab analysis to measure the amount of ketone bodies in blood, serum, or plasma specimen [HCPCS 82010]",75.6,56.7,56.7,28.88,8.3,45.2,,,,,,00143-9784-10 - flumazenil 0.1 mg/mL IV Sol MDV [REEV],J3490,0250,00143-9784-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82024,Lab analysis to measure the adrenocorticotropic hormone (ACTH) level [HCPCS 82024],362.8,272.1,272.1,220.58,152.02,362.8,,,,,,"00409-2721-01 - heparin 10,000 units/mL Inj Sol [REEV]",J1644,0250,00409-2721-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,0,5.03,33.1,,,,,,63323-0614-16 - hydrALAZINE 20 mg/mL Inj Sol [REEV],J0360,0250,63323-0614-16,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,16.11,2.31,20.91,,,,,,47781-0586-29 - labetalol 5 mg/mL IV Sol [REEV],J3490,0250,47781-0586-29,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,58.37,5.44,96,,,,,,51754-1000-04 - magnesium sulfate 50% Inj Sol 10 mL [REEV],J3475,0250,51754-1000-04,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82180,Lab analysis to measure the ascorbic acid (Vitamin C) level in blood specimen [HCPCS 82180],121.3,90.98,90.98,70.92,70.92,70.92,,,,,,70069-0071-10 - naloxone 0.4 mg/mL Inj Sol [REEV],J2310,0250,70069-0071-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],118.1,88.58,88.58,69.01,4.22,71.8,,,,,,14789-0012-02 - nitroprusside 25 mg/mL IV Sol [REEV],,0250,14789-0012-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],30.9,23.18,23.18,18.79,12.94,18.79,,,,,,36000-0162-10 - norEPINEPHrine 1 mg/mL IV Sol [REEV],,0250,36000-0162-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,29.67,16.18,45.86,,,,,,23155-0547-42 - ondansetron 2 mg/mL Inj Sol [REEV],J2405,0250,23155-0547-42,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,290.1,30.08,290.1,,,,,,55150-0125-02 - ondansetron 2 mg/mL Inj Sol [REEV],J2405,0250,55150-0125-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,30.95,4.42,42.84,,,,,,36000-0012-25 - ondansetron 2 mg/mL Inj Sol [REEV],J2405,0250,36000-0012-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82530,Lab analysis to measure the amount of free cortisol (hormone) [HCPCS 82530],237.1,177.83,177.83,144.16,16.71,233.8,,,,,,63323-0965-10 - potassium chloride 2 mEq/mL 10 mL IV Sol [REEV],J3480,0250,63323-0965-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,39.58,5.81,65.1,,,,,,23155-0523-41 - prochlorperazine 5 mg/mL Inj Sol [REEV],J0780,0250,23155-0523-41,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,60.37,11.55,98.31,,,,,,64679-0728-01 - SUMAtriptan 6 mg/0.5 mL SubQ Sol [REEV],J3030,0250,64679-0728-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,59.04,4.35,81.23,,,,,,63323-0781-10 - vecuronium 10 mg IV Inj [REEV],J3490,0250,63323-0781-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,75.82,12.67,98.39,,,,,,51754-0203-02 - verapamil 2.5 mg/mL IV Sol [REEV],,0250,51754-0203-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,465.3,32.34,465.3,,,,,,63323-0185-10 - sterile water 10 mL Inj Sol [REEV],,0250,63323-0185-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],480.7,360.53,360.53,146.16,28.4,180.6,,,,,,76329-3316-01 - EPINEPHrine 0.1 mg/mL Inj Sol [REEV],J0171,0250,76329-3316-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82672,Lab analysis to identify total estrogen [HCPCS 82672],255.8,191.85,191.85,155.53,155.53,255.8,,,,,,68982-0643-01 - albumin human 25% IV Sol 50 mL [REEV],,0250,68982-0643-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,71.8,11.45,112.4,,,,,,00641-6116-10 - ampicillin-sulbactam 1 g-0.5 g Inj [REEV],J0295,0250,00641-6116-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,148.17,14.94,192.28,,,,,,00049-0014-83 - ampicillin-sulbactam 2 g-1 g Inj [REEV],J0295,0250,00049-0014-83,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82803,Lab analysis to measure the amount of blood gases [HCPCS 82803],293.3,219.98,219.98,142.82,26.5,223.7,,,,,,25021-0127-20 - cefTAZidime 1 g Inj [REEV],J0713,0250,25021-0127-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,48.28,3.99,48.28,,,,,,63323-0322-25 - imipenem-cilastatin 500 mg Inj [REEV],J0743,0250,63323-0322-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,50.95,10.81,66.12,,,,,,63323-0507-25 - meropenem 500 mg IV Inj [REEV],J2185,0250,63323-0507-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.59,2.66,8.7,,,,,,55150-0122-15 - nafcillin 1 g Inj [REEV],,0250,55150-0122-15,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82977,Lab analysis to measure the glutamyltransferase (liver enzyme) level [HCPCS 82977],65.1,48.83,48.83,38.07,11.93,52.08,,,,,,63323-0328-20 - nafcillin 2 g Inj [REEV],,0250,63323-0328-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,134.06,16.1,220.5,,,,,,55150-0120-30 - piperacillin-tazobactam 3 g-0.375 g IV Inj [REEV],J2543,0250,55150-0120-30,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",399.1,299.33,299.33,108.59,18.83,178.6,,,,,,63323-0300-36 - piperacillin-tazobactam 3 g-0.375 g IV Inj [REEV],J2543,0250,63323-0300-36,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,188.42,56.58,188.42,,,,,,63323-0306-02 - tobramycin 40 mg/mL Inj Sol [REEV],J3260,0250,63323-0306-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,70.47,8.16,104.31,,,,,,67457-0339-50 - vancomycin 500 mg IV Inj [REEV],J3370,0250,67457-0339-50,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,214.5,11.58,453.2,,,,,,00338-9541-24 - metroNIDAZOLE 500 mg/100 mL IV Sol [REEV],J3490,0250,00338-9541-24,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83520,Lab analysis to measure the amount of substance by other immunoassay technique [HCPCS 83520],551.3,413.48,413.48,335.19,335.19,335.19,,,,,,00406-0124-62 - acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [REEV],,0250,00406-0124-62,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83525,Lab analysis to measure the amount of total insulin [HCPCS 83525],147.8,110.85,110.85,89.86,18.95,89.86,,,,,,13107-0021-01 - acetaminophen-HYDROcodone 325 mg-10 mg Tab [REEV],,0250,13107-0021-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,30.89,5.43,33.59,,,,,,00409-1253-01 - meperidine 50 mg/mL Inj Sol [REEV],J2175,0250,00409-1253-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,35.57,7.34,38.68,,,,,,00641-0121-25 - HYDROmorphone 2 mg/mL Inj Sol [REEV],J1170,0250,00641-0121-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,118.01,9.72,190.22,,,,,,00409-3459-07 - HYDROmorphone 2 mg/mL Inj Sol [REEV],J1170,0250,00409-3459-07,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,94.54,5.07,94.54,,,,,,60505-7006-02 - fentaNYL 25 mcg/hr Transderm ER Film [REEV],,0250,60505-7006-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,64.39,5,105.9,,,,,,47781-0424-47 - fentaNYL 25 mcg/hr Transderm ER Film [REEV],,0250,47781-0424-47,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],61.8,46.35,46.35,37.57,37.57,37.57,,,,,,47781-0426-47 - fentaNYL 50 mcg/hr Transderm ER Film [REEV],,0250,47781-0426-47,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,44.26,5.63,72.8,,,,,,60505-7008-02 - fentaNYL 75 mcg/hr Transderm ER Film [REEV],,0250,60505-7008-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,171.64,32.98,268.8,,,,,,60505-7009-02 - fentaNYL 100 mcg/hr Transderm ER Film [REEV],,0250,60505-7009-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,122.76,41.96,133.85,,,,,,51079-0788-20 - ALPRAZolam 0.25 mg Tab [REEV],,0250,51079-0788-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84030,"Lab analysis to measure the phenylalanine, PKU (amino acid) level in blood specimen [HCPCS 84030]",102.6,76.95,76.95,29.9,4.62,77.09,,,,,,51079-0285-20 - diazepam 5 mg Tab [REEV],,0250,51079-0285-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,32.22,4.75,40.9,,,,,,69315-0904-01 - LORazepam 0.5 mg Tab [REEV],,0250,69315-0904-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],144.5,108.38,108.38,87.86,18.12,87.86,,,,,,63739-0201-10 - PHENobarbital 32.4 mg Tab [REEV],,0250,63739-0201-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,112.66,19.44,112.66,,,,,,00143-9509-10 - ketamine 100 mg/mL Inj Sol [REEV],,0250,00143-9509-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,191.76,18.45,315.4,,,,,,47781-0588-68 - midazolam 1 mg/mL Inj Sol [REEV],J2250,0250,47781-0588-68,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84154,Lab analysis to measure the amount of free PSA (prostate specific antigen) in serum specimen [HCPCS 84154],222.7,167.03,167.03,135.4,93.32,135.4,,,,,,50383-0087-12 - codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 10 mL [REEV],,0250,50383-0087-12,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,35.57,3.73,46.16,,,,,,00009-0417-01 - testosterone cypionate 200 mg/mL IM Sol (PHS) [REEV],J1071,0250,00009-0417-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84270,Lab analysis to measure the sex hormone binding globulin (protein) level in serum specimen [HCPCS 84270],240.4,180.3,180.3,146.16,22.08,180.6,,,,,,00574-4024-39 - erythromycin Ophth 0.5% Oint [REEV],,0250,00574-4024-39,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84402,Lab analysis to measure free testosterone (hormone) level in serum specimen [HCPCS 84402],148.9,111.68,111.68,90.53,25.55,148.9,,,,,,17478-0070-31 - erythromycin Ophth 0.5% Oint [REEV],,0250,17478-0070-31,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,146.16,25.9,240.4,,,,,,68001-0151-00 - carvedilol 12.5 mg Tab [REEV],,0250,68001-0151-00,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84425,Lab analysis to measure the vitamin B-1 (thiamine) level in blood specimen [HCPCS 84425],311,233.25,233.25,189.09,130.28,245.38,,,,,,00574-0120-08 - charcoal-sorbitol 50 g Oral Susp 240 mL [REEV],,0250,00574-0120-08,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,79.1,7.58,134.6,,,,,,96375 IV PUSH DIFFERENT MED CHARGE,96375,0260,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,82.51,14.11,134.34,,,,,,"Immunofixation, Urine REF",86335,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,38.07,4.35,39.58,,,,,,"Cell Count And Diff, Pleural Fluid REF",89051,0300,,70.6,52.95,52.95
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",65.1,48.83,48.83,38.07,5.38,38.07,,,,,,"Creatinine, 24 Hour Urine REF",82570,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,30.95,5.83,44.1,,,,,,"Culture, Urine, Routine REF",87086,0300,,108.1,81.075,81.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,94.54,14.41,153.94,,,,,,"Hydroxyindoleacetic Acid, 5-,Urine,24 Hr REF",81005,0300,,111.4,83.55,83.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,85.85,9.87,141.2,,,,,,"Myoglobin, Urine REF",83874,0300,,145.6,109.2,109.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,32.22,4.54,50.4,,,,,,"Protein Electrophoresis, 24 hour Urine REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84590,Lab analysis to measure the vitamin A level in serum specimen [HCPCS 84590],30.5,22.88,22.88,17.82,17.82,17.82,,,,,,"Protein, Ttl W/Creat, 24 Hour Urine REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,118.68,17.05,191.3,,,,,,"Vma, 24 Hour Urine w/out Creatinine REF",84585,0300,,110.3,82.725,82.725
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,82.52,12.64,85.85,,,,,,"Protein, Ttl W/Creat, Random Urine REF",82570,0300,,97.1,72.825,72.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,37.57,7.65,55.26,,,,,,"Crystals, Fluid REF",89060,0300,,75,56.25,56.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.63,6,88.2,,,,,,"Uric Acid, Synovial Fluid REF",84560,0300,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,22.8,5.43,37.5,,,,,,"Microalbumin, 24 Hour Urine (w/o Creatinine) REF",82043,0300,,148.9,111.675,111.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,116.68,8.55,182.7,,,,,,"Cell Count And Diff, Synovial Fluid REF",89051,0300,,55.2,41.4,41.4
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,42.32,3.6,69.6,,,,,,"Ph, Body Fluid REF",83986,0300,,25.5,19.125,19.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,25.79,3.56,42,,,,,,Complete Synovial Fluid Analysis REF,89051,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,41.53,2.7,54.33,,,,,,"Creatinine, Random Urine REF",82570,0300,,97.1,72.825,72.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,42.32,6.03,69.6,,,,,,"Cortisol, Free 24-Hour Urine Lc/Ms/Ms REF",82530,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86021,Lab analysis to identify antibodies to white blood cells [HCPCS 86021],1088.3,816.23,816.23,661.69,27.1,661.69,,,,,,"Protein, Ttl And Protein Electrophoresis, Random Urine REF",84166,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,90.93,12.29,258.33,,,,,,"Protein, Ttl, 24 Hour Urine (w/o Creatinine) REF",84156,0300,,58.5,43.875,43.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,44.52,5.26,76.2,,,,,,"Chloride w/o Creatinine, Random Urine REF",82436,0300,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,83.81,12.2,112.96,,,,,,"Potassium w/o Creatinine, Random Urine REF",84133,0300,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86162,Lab analysis to measure the amount of total hemolytic (CH50) of immune system proteins (complement) [HCPCS 86162],131.3,98.48,98.48,76.75,76.75,76.75,,,,,,"Sodium w/o Creatinine, Random Urine REF",84300,0300,,39.7,29.775,29.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86225,Lab analysis to identify antibodies to native or double stranded DNA [HCPCS 86225],141.2,105.9,105.9,85.85,62.13,112.96,,,,,,"Urine Protein, Ttl, Random (w/o Creatinine) REF",84156,0300,,58.5,43.875,43.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86308,Lab analysis to screen for mononucleosis (mono) [HCPCS 86308],53,39.75,39.75,30.95,5.26,30.95,,,,,,"Amphetamine Confirmation By Gcms, Urine REF",80359,0300,,188.6,141.45,141.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,73.75,14.79,121.3,,,,,,"Metanephrines, Fract. Lc/Ms/Ms, 24 Hr Urine REF",83835,0300,,409.1,306.825,306.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,113.33,5.76,186.4,,,,,,"Albumin, Peritoneal Fluid REF",82042,0300,,55.2,41.4,41.4
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],421.2,315.9,315.9,246.28,176.48,278.51,,,,,,"Ld, Pleural Fluid REF",83615,0300,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,37.57,4.34,61.8,,,,,,"Kappa/Lambda Light Chains Ttl, Random Urine REF",83883,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86593,Lab analysis to identify syphilis for monitoring or re-infection of the disease [HCPCS 86593],30.9,23.18,23.18,18.79,7.3,18.79,,,,,,"Oxycodone, Confirmation By Gc/Ms, Urine REF",80365,0300,,272.4,204.3,204.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86671,Lab analysis to identify antibodies to fungus (not elsewhere specified) [HCPCS 86671],171,128.25,128.25,103.97,103.97,103.97,,,,,,"Culture, CSF REF",87070,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86695,"Lab analysis to identify antibodies to Herpes simplex virus, type 1 [HCPCS 86695]",194.1,145.58,145.58,58.37,13.41,58.37,,,,,,"Glucose, CSF REF",82945,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86696,"Lab analysis to identify antibodies to Herpes simplex virus, type 2 [HCPCS 86696]",413.5,310.13,310.13,58.37,19.67,254.75,,,,,,"Protein, Ttl, Csf REF",84157,0300,,86,64.5,64.5
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,73.75,11.52,121.3,,,,,,"Calprotectin, Stool REF",83993,0300,,290.1,217.575,217.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86735,Lab analysis to identify antibodies to mumps virus [HCPCS 86735],161,120.75,120.75,71.8,71.8,71.8,,,,,,Cryptococcus Ab Ifa (Csf) REF,86641,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86762,Lab analysis to identify antibodies to Rubella (German measles virus) [HCPCS 86762],237.1,177.83,177.83,116.01,116.01,116.01,,,,,,"Helicobacter Pylori Ag, Eia, Stool REF",87339,0300,,217.3,162.975,162.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86765,Lab analysis to identify antibodies to Rubeola (measles virus) [HCPCS 86765],169.8,127.35,127.35,53.63,10.82,53.63,,,,,,Acetylcholine Receptor Binding Ab REF,83519,0300,,317.6,238.2,238.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,54.83,16.62,74.01,,,,,,"ACTH, Plasma REF",82024,0300,,362.8,272.1,272.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86780,Lab analysis to identify antibodies to Treponema pallidum [HCPCS 86780],311,233.25,233.25,75.82,21.95,75.82,,,,,,Aldolase REF,82085,0300,,94.9,71.175,71.175
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86787,Lab analysis to identify antibodies to varicella-zoster virus (chicken pox) [HCPCS 86787],148.9,111.68,111.68,90.53,10.82,90.53,,,,,,Alpha-1-Antitrypsin Qn REF,82103,0300,,124.7,93.525,93.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,135.4,11.99,222.7,,,,,,"Alpha Fetoprotein, Tumor Marker REF",82105,0300,,139,104.25,104.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,47.67,6.74,92.02,,,,,,.Amylase REF,82150,0300,,96,72,72
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,37.57,2.99,62.24,,,,,,"ANA Scrn, Ifa, w/Refl Titer And Pattern REF",86038,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,29.55,2.99,48.11,,,,,,DNA (Ds) Ab REF,86225,0300,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,75.09,11.93,144.95,,,,,,DNAse B Ab REF,86215,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,85.85,9.2,112.32,,,,,,Glomerular Basement Membrane Ab (IgG) REF,83520,0300,,322,241.5,241.5
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,58.02,7.24,496.86,,,,,,Mitochondrial Ab w/Refl Titer REF,86255,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,86.39,9.38,86.39,,,,,,Anti-Streptolysin O REF,86060,0300,,48.6,36.45,36.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,61.04,6.79,100.4,,,,,,Thyroglobulin Abs REF,86800,0300,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,65.72,2.84,108.1,,,,,,"Arsenic, Blood REF",82175,0300,,226.1,169.575,169.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,15.08,6.8,52.43,,,,,,"C1 Esterase Inhibitor, Protein REF",86160,0300,,168.8,126.6,126.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,104.58,7.27,172,,,,,,"Calcium, Ionized REF",82330,0300,,88.2,66.15,66.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,30.33,4.29,39.3,,,,,,"Carboxyhemoglobin, Blood REF",82375,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87255,Lab analysis of isolated viruses by non-immunologic method [HCPCS 87255],326.4,244.8,244.8,198.45,56.12,198.45,,,,,,"Catecholamines, Fraction, 24 Hr Ur w/o Creatinine REF",82384,0300,,275.7,206.775,206.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87390,Lab analysis by immunoassay (ELISA) to identify HIV-1 [HCPCS 87390],166.6,124.95,124.95,101.29,101.29,101.29,,,,,,Ceruloplasmin REF,82390,0300,,69.6,52.2,52.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,90.93,8.17,155.5,,,,,,"Carbamazepine, Ttl REF",80156,0300,,110.3,82.725,82.725
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,90.93,11.68,116.85,,,,,,"Cholesterol, Ttl REF",82465,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,67.06,37.79,110.3,,,,,,"Factor Viii Activity, Clotting REF",85240,0300,,271.3,203.475,203.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,45.8,14.12,74.6,,,,,,Complement Component C3C REF,86160,0302,,145.6,109.2,109.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,94.54,29.48,155.5,,,,,,Complement Component C4C REF,86160,0300,,122.5,91.875,91.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,94.54,29.48,155.5,,,,,,Coag Factor Xi Activity REF,85270,0300,,434.4,325.8,325.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,10.76,4.29,35.67,,,,,,Copper REF,82525,0300,,163.2,122.4,122.4
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,95.76,58.97,116.37,,,,,,"Cortisol, Ttl REF",82530,0300,,237.1,177.825,177.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,96.71,45.82,378.9,,,,,,C-Peptide REF,84681,0300,,195.2,146.4,146.4
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,63.84,29.48,105,,,,,,"Culture, Blood #1 REF",87040,0300,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,406.9,40.24,406.9,,,,,,"Culture, Throat REF",87070,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,88108,Lab examination of specimen by the conentration technique to diagnose disease [HCPCS 88108],33.1,24.83,24.83,20.12,13.86,38.85,,,,,,Dhea Sulfate REF,82626,0300,,275.7,206.775,206.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,10.76,4.29,27.04,,,,,,Cytomegalovirus Ab (IgG) REF,86644,0300,,186.4,139.8,139.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,20.13,13.86,24.19,,,,,,Amitriptyline REF,80335,0300,,180.9,135.675,135.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,20.12,20.12,77.89,,,,,,Erythropoietin REF,82668,0300,,248.2,186.15,186.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,92950,Heart and lungs restart (attempt) [HCPCS 92950],695.8,521.85,521.85,99.96,71.63,200.7,,,,,,"Estrogen, Ttl, Serum REF",82672,0300,,255.8,191.85,191.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,74.48,6.15,4344.87,,,,,,"Fecal Lipids, Ttl REF",82710,0300,,345.2,258.9,258.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],469.7,352.28,352.28,285.58,196.81,380.21,,,,,,.Ferritin REF,82728,0300,,118.1,88.575,88.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,284.97,39.27,311.42,,,,,,"Fibrinogen Degradation Products (FDP), Semi Qn REF",85362,0300,,101.5,76.125,76.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],713.4,535.05,535.05,433.75,307.94,471.72,,,,,,"Fibrinogen Activity, Clauss REF",85384,0300,,96,72,72
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93925,Leg ultrasound of arteries and arterial grafts of both legs (complete study) [HCPCS 93925],1018.8,764.1,764.1,619.43,350.85,673.66,,,,,,"Folate, Serum REF",82746,0300,,243.7,182.775,182.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93931,Arteries and arterial grafts ultrasound of one arm (limited study) [HCPCS 93931],680.3,510.23,510.23,413.62,413.62,413.62,,,,,,Fsh REF,83001,0300,,220.5,165.375,165.375
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",1427.8,1070.85,1070.85,868.1,350.85,944.09,,,,,,Gastrin REF,83516,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,433.75,166.13,1092.27,,,,,,Gram Stain REF,87205,0300,,160,120,120
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,94060,Amount and speed of breathed air measurement and graphic recording before and after medication administration [HCPCS 94060],308.7,231.53,231.53,180.52,20,362.32,,,,,,Hepatitis B Surface Ag w/Refl Confirm REF,87340,0300,,105.9,79.425,79.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,50.95,16.49,98.36,,,,,,Hepatitis B Surface Ab Ql REF,86706,0300,,113.7,85.275,85.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,50.95,19.15,448.97,,,,,,"Glucose-6-Phosphate Dehydrogenase, Qn REF",82955,0300,,87.2,65.4,65.4
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,271.53,28.6,1161.38,,,,,,Hepatitis B Core Ab Ttl REF,86704,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,45.13,16.26,2475.42,,,,,,Haptoglobin REF,83010,0300,,134.5,100.875,100.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,271.53,68.61,524.17,,,,,,"Hepatitis A Ab, Ttl REF",86708,0300,,113.7,85.275,85.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,59.04,20.72,3197.1,,,,,,Hepatitis A IgM REF,86709,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,49.61,34.19,143.78,,,,,,Growth Hormone (Gh) REF,83003,0300,,135.7,101.775,101.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96368,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (concurrent with another infusion) [HCPCS 96368]",92.7,69.53,69.53,47.71,38.81,108.8,,,,,,HLA-B27 Ag REF,86812,0300,,226.1,169.575,169.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,47.67,4.51,1156.79,,,,,,Immunoglobulin A REF,82784,0300,,100.4,75.3,75.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,121.36,29.4,2785.69,,,,,,Immunoglobulin E REF,82785,0300,,135.7,101.775,101.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,24.14,12.56,48.28,,,,,,Immunoglobulin G REF,82784,0300,,90.4,67.8,67.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,21.92,10.24,44.01,,,,,,Immunoglobulin M REF,82784,0300,,90.4,67.8,67.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,28.37,13.42,41.31,,,,,,"Immunofixation, Serum REF",86320,0300,,164.4,123.3,123.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97014,Electrical stimulation application to 1 or more areas (unattended by physical therapist) [HCPCS 97014],62.9,47.18,47.18,38.24,38.24,38.24,,,,,,Hepatitis Be Ag REF,87350,0300,,107,80.25,80.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,68.4,40.84,136.8,,,,,,Hepatitis Be Ab REF,86707,0300,,107,80.25,80.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,74.48,40.84,143.78,,,,,,Insulin REF,83525,0300,,147.8,110.85,110.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],101.5,76.13,76.13,61.71,37.78,80.08,,,,,,"Iron, Ttl REF",83540,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,49,23.51,98.36,,,,,,"Lactic Acid, Plasma REF",83605,0300,,194.1,145.575,145.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,221.92,140.59,428.4,,,,,,LD REF,83615,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,221.92,140.59,241.75,,,,,,"Lead, Blood REF",83655,0300,,123.5,92.625,92.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],247,185.25,185.25,144.41,103.49,144.41,,,,,,.Lipase REF,83690,0300,,105.9,79.425,79.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,79.83,40.84,154.11,,,,,,HDL Cholesterol REF,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97605,Wound vac therapy (negative pressure wound therapy) with DME (durable medical equipment) per session (surface area less than or equal to 50 square cm) [HCPCS 97605],709,531.75,531.75,215.54,215.54,401.51,,,,,,Lithium REF,80178,0300,,79.4,59.55,59.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,10.76,10.32,28.14,,,,,,Lh REF,83002,0300,,178.6,133.95,133.95
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,53.91,35.11,337.46,,,,,,"Complement, Ttl (Ch50) REF",86162,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,86.35,70.45,319.43,,,,,,Lysozyme (Muramidase) REF,85549,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,107.28,315.01,,,,,,.Magnesium REF,83735,0300,,49.7,37.275,37.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,79.83,2.2,117.5,,,,,,"Magnesium, RBC REF",83735,0300,,115.9,86.925,86.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,"Mercury, Blood REF",83825,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,234.02,61.48,2109.82,,,,,,"Treponema Pallidum Ab, Particle Agglutination REF",86780,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,346.62,50,3116.59,,,,,,Mycoplasma Pneumoniae Ab (IgG) REF,86738,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,569.15,62.92,1098.7,,,,,,"Myoglobin, Serum REF",83874,0300,,189.7,142.275,142.275
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,14.77,5.83,3301.98,,,,,,5'Nucleotidase REF,83915,0300,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0153,Adenosine inj 1mg [HCPCS J0153],16.43,12.32,12.32,9.99,9.99,9.99,,,,,,Osmolality (Serum) REF,83930,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0171,Adrenalin epinephrine inject [HCPCS J0171],2.5,1.88,1.88,1.54,0.8,1.67,,,,,,Osmolality (Ur) REF,83935,0300,,145.6,109.2,109.2
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0282,Amiodarone hcl [HCPCS J0282],11.54,8.66,8.66,7.08,3.34,7.08,,,,,,"Ova And Parasites, Conc And Perm Smear REF",87209,0300,,56.8,42.6,42.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0330,Succinycholine chloride inj [HCPCS J0330],3.95,2.96,2.96,2.43,1.74,3.04,,,,,,Chlamydiae Species Culture REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],31.47,23.6,23.6,19.14,15.1,23.42,,,,,,Rotavirus Ag Detection REF,87425,0300,,207.3,155.475,155.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,7.68,5.5,14.67,,,,,,Phenobarbital REF,80345,0300,,121.3,90.975,90.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0694,Cefoxitin sodium injection [HCPCS J0694],25,18.75,18.75,15.35,6.27,15.35,,,,,,.Phenytoin REF,80185,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,3.8,0.68,2868.2,,,,,,Phosphate (As Phosphorus) REF,84100,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,34.08,13.53,65.14,,,,,,Progesterone REF,84144,0300,,144.5,108.375,108.375
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,1.52,0.11,332.88,,,,,,Prolactin REF,84146,0300,,185.3,138.975,138.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,15.2,2.1,2819.66,,,,,,"Protein, Ttl And Protein Electrophoresis REF",84165,0300,,186.4,139.8,139.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,3.07,1.1,3.07,,,,,,"Amino Acid Analysis, Lc/Ms, Plasma REF",82139,0300,,620.8,465.6,465.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1650,Inj enoxaparin sodium [HCPCS J1650],14.44,10.83,10.83,8.78,0.47,8.78,,,,,,Reticulocyte Count REF,85045,0300,,100.4,75.3,75.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,15.2,5.5,1162.88,,,,,,"Ab Scrn, RBC w/Refl Id, Titer And Ag REF",86850,0300,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,1.54,0.73,808.23,,,,,,RPR (Monitor) w/Refl Titer REF,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,15.2,7.08,29.34,,,,,,Rubella Immune Status REF,86762,0300,,237.1,177.825,177.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,15.2,7.8,30.4,,,,,,Doxepin REF,80335,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,7.6,5.5,14.67,,,,,,Malaria/Babesia/Other Blood Parasites REF,87168,0300,,199.6,149.7,149.7
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,15.35,3.15,30.39,,,,,,Pathologist Review Of Peripheral Smear REF,85060,0300,,78.4,58.8,58.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,15.2,11,29.34,,,,,,"IGF 1, Lc/Ms REF",84305,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.6,0.95,3583.7,,,,,,Amylase Isoenzymes REF,82150,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,5.12,1.72,16.28,,,,,,"Beta 2 Microglobulin, Serum REF",82232,0300,,121.3,90.975,90.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,15.35,2.81,811.33,,,,,,Alpha-1-Antitrypsin (Aat) Phenotype REF,82104,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.76,0.55,29.34,,,,,,"T3, Ttl REF",84480,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2920,Methylprednisolone injection [HCPCS J2920],25,18.75,18.75,15.35,5.3,21.25,,,,,,T3 Uptake REF,84479,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,17.68,5.49,347.63,,,,,,".T4, Free REF",84439,0300,,130.1,97.575,97.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],8.33,6.25,6.25,5.12,5.12,5.12,,,,,,"T4 (Thyroxine), Ttl REF",84436,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J3101,Tenecteplase injection [HCPCS J3101],142.68,107.01,107.01,87.61,87.61,87.61,,,,,,"Testosterone, Ttl, Males (Adult), Ia REF",84403,0300,,240.4,180.3,180.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,1.29,1.29,348.28,,,,,,Thrombin Clotting Time REF,85670,0300,,389.3,291.975,291.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,7.6,5.5,19.14,,,,,,Imipramine REF,80335,0300,,218.3,163.725,163.725
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],20,15,15,1.52,0.84,14.68,,,,,,Transferrin REF,84466,0300,,111.4,83.55,83.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,12.28,1.66,23.47,,,,,,.Triglycerides REF,84478,0300,,35.3,26.475,26.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,12.28,1.76,23.48,,,,,,.TSH REF,84443,0300,,135.7,101.775,101.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,21.28,0.02,4433.9,,,,,,Uric Acid REF,84550,0300,,53,39.75,39.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J7614,Levalbuterol non-comp unit [HCPCS J7614],5.58,4.19,4.19,3.39,3.39,5.7,,,,,,"Coccidioides Ab, Cf REF",86635,0300,,178.6,133.95,133.95
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J7633,Budesonide non-comp con [HCPCS J7633],27.7,20.78,20.78,9.12,9.12,482.83,,,,,,"Coccidioides Ab, Id REF",86635,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J7644,Ipratropium bromide non-comp [HCPCS J7644],5,3.75,3.75,3.04,3.04,3.04,,,,,,Valproic Acid REF,80164,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,310.08,167.53,728.8,,,,,,"Vitamin B6, Plasma REF",84207,0300,,426.8,320.1,320.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,952,Anesthesia provided during uterus examination using an endoscope [HCPCS 00952],12.72,9.54,9.54,5.7,5.7,5.7,,,,,,Vitamin B12 REF,82607,0300,,124.7,93.525,93.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",314,235.5,235.5,93.5,55.67,329.7,,,,,,"Vitamin C, Lc/Ms/Ms REF",82180,0300,,121.3,90.975,90.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],194.3,145.73,145.73,77,73.93,98.64,,,,,,Zinc REF,84630,0300,,135.7,101.775,101.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],83,62.25,62.25,41.81,35.71,43.32,,,,,,Measles Ab (IgG) REF,86765,0300,,88.2,66.15,66.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,300,Anesthesia provided during esophagus and neck procedure [HCPCS 00300],139,104.25,104.25,6.45,6.45,46.89,,,,,,CEA REF,82378,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,6.16,3.97,330,,,,,,Neutrophil Ab Flow Cytometry REF,86021,0300,,318.7,239.025,239.025
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",139,104.25,104.25,11.15,8.77,11.15,,,,,,"Protein C, Activity REF",85303,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,5.55,1.64,80.91,,,,,,"Protein S, Activity REF",85306,0300,,281.2,210.9,210.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,3.68,1.93,464.4,,,,,,Bermuda Grass (G2) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel procedure with endoscope [HCPCS 00813]",139,104.25,104.25,6.14,5.44,556,,,,,,Timothy Grass (G6) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,5.78,4.8,352,,,,,,June Grass(Kentucky Blue) (G8) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,1730,Anesthesia provided during closed procedure on upper arm and elbow [HCPCS 01730],139,104.25,104.25,132.3,132.3,132.3,,,,,,Common Ragweed (Short) (W1) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,1961,Anesthesia provided during cesarean delivery [HCPCS 01961],139,104.25,104.25,7.92,5.74,329.73,,,,,,Giant Ragweed (Tall) (W3) IgE REF,86003,0300,,39.7,29.775,29.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,8.03,3.36,245.34,,,,,,Russian Thistle (W11) IgE REF,86003,0300,,48.6,36.45,36.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,10080,Tailbone cyst incision and drainage (simple procedure) [HCPCS 10080],1554.93,1166.2,1166.2,124.85,124.85,188.49,,,,,,Rough Pigweed (W14) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,11402,"Removal of non-cancerous skin lesion of trunk, arms, or legs (1.1 to 2.0 cm) [HCPCS 11402]",739.9,554.93,554.93,69.3,69.3,251.52,,,,,,Scale (W15) IgE REF,86003,0300,,51.9,38.925,38.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,11404,"Removal of non-cancerous skin lesion of trunk, arms, or legs (3.1 to 4.0 cm) [HCPCS 11404]",830.3,622.73,622.73,195.25,195.25,260.87,,,,,,Firebush (W17) IgE REF,86003,0300,,29.9,22.425,22.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,11442,"Removal of non-cancerous skin lesion of face, ears, eyelids, nose, lips, or mouth (1.1 to 2.0 cm) [HCPCS 11442]",837.9,628.43,628.43,90.75,90.75,232.38,,,,,,Mountain Cedar (T6) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1340.7,1005.53,1005.53,226.6,65.83,226.6,,,,,,Oak (T7) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,286,51.74,302.2,,,,,,Mesquite Tree (T20) IgE REF,86003,0300,,29.9,22.425,22.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,343.2,192.01,343.2,,,,,,Sweet Potato (F54) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,406.99,168.37,416.16,,,,,,Cat Dander (E1) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,140.8,79.43,766.3,,,,,,Dog Dander (E5) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,1274.36,138.2,1470.79,,,,,,Cashew Nut (F202) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,Herpes Simplex Virus Culture W/Rfl To Typing REF,87255,0300,,326.4,244.8,244.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,93.5,52.38,170.1,,,,,,Mouse Epithelia (E71) IgE REF,86003,0300,,51.9,38.925,38.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,88,52.53,206.9,,,,,,"Varicella Zoster Virus Culture, Rapid Method REF",87254,0300,,209.5,157.125,157.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,144.65,81.71,178.67,,,,,,Herpes Simplex Virus Culture REF,87254,0300,,419,314.25,314.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,0,95.05,222.03,,,,,,Aspergillus FumIgAtus (M3) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,79.76,39.55,134.08,,,,,,AlteRNAria AlteRNAta (M6) IgE REF,86003,0300,,29.9,22.425,22.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,0,45.48,91.29,,,,,,Mackerel (F206) IgE ** REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,176.55,114.76,176.55,,,,,,Dermatophagoides Pteronyssinus (D1) IgE REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,93.5,59.99,274.04,,,,,,Dermatophagoides Farinae (D2) IgE REF,86003,0300,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,77,77,101.03,,,,,,Egg White (F1) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,0,38.82,44.36,,,,,,Cow'S Milk (F2) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,0,2.09,3.53,,,,,,Codfish (F3) IgE REF,86003,0300,,44.1,33.075,33.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,5.3,4.51,1156.79,,,,,,Wheat (F4) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,53.91,35.11,337.46,,,,,,Peanut (F13) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,86.35,70.45,319.43,,,,,,Soybean (F14) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Institutional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],65.1,48.83,48.83,68.4,65.1,236.48,,,,,,Almond (F20) IgE REF,86003,0300,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.14,2.07,19.9,,,,,,Crab (F23) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,14,12.82,82,,,,,,Shrimp (F24) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,Tuna (F40) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,Salmon (F41) IgE REF,86003,0300,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,Garlic (F47) IgE REF,86003,0300,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,Onion (F48) IgE REF,86003,0300,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,Lobster (F80) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,Egg Yolk (F75) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,Pecan Nut (F201) IgE REF,86003,0300,,37.5,28.125,28.125
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Clinic,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],26.3,19.73,19.73,6.12,5.39,19.43,,,,,,Trout (F204) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,166.67,55,166.67,,,,,,"Phenytoin, Free REF",80186,0300,,105.9,79.425,79.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.77,2.44,580.94,,,,,,Pine (T213) IgE ** REF,86003,0300,,29.9,22.425,22.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,152.24,20.71,250.4,,,,,,Walnut (F256) IgE REF,86003,0300,,44.1,33.075,33.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,131.52,94.25,222.4,,,,,,"HSV 1 IgG, Type Specific Ab REF",86695,0300,,96,72,72
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,131.52,90,225,,,,,,"HSV 2 IgG, Type Specific Ab REF",86696,0300,,194.1,145.575,145.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,437.11,92.55,635.38,,,,,,Toxoplasma Ab (IgG) REF,86777,0300,,134.5,100.875,100.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,Actinomyces Culture REF,87081,0300,,290.1,217.575,217.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,90.93,43.35,182.52,,,,,,Fecal Leukocyte Stain REF,89055,0300,,65.1,48.825,48.825
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,90.53,11.25,148.9,,,,,,"Fecal Fat, Qualitative REF",82705,0300,,105.9,79.425,79.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,174.07,14.4,297.7,,,,,,Estradiol REF,82670,0300,,240.4,180.3,180.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,181.81,63.16,518.42,,,,,,FTA-Abs REF,86780,0300,,124.7,93.525,93.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,52.29,9.42,73.71,,,,,,"Cortisol, A.M. REF",82533,0300,,135.7,101.775,101.775
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,44.52,2.66,76.2,,,,,,Rheumatoid Factor REF,86431,0300,,186.4,139.8,139.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,30.95,1.89,53,,,,,,C-Reactive Protein REF,86140,0300,,76.2,57.15,57.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,47.71,6.2,81.6,,,,,,"Culture, Aerobic And Anaerobic W/Gram Stain REF",87070,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,176.38,30.08,290.1,,,,,,Plasminogen Activity REF,85420,0300,,204.1,153.075,153.075
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,82330,Lab analysis to measure the ionized calcium level in blood specimen [HCPCS 82330],88.2,66.15,66.15,53.63,53.63,53.63,,,,,,"Culture, Anaerobic Bacteria W/Gram Stain REF",87075,0300,,147.8,110.85,110.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,39.58,5.81,65.1,,,,,,"Campylobacter, Culture REF",87046,0300,,48.6,36.45,36.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,188.42,56.58,188.42,,,,,,"Culture, Ear, External REF",87070,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,67.72,8.16,104.31,,,,,,"Culture, Surveillance REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,30.89,5.43,33.59,,,,,,"Culture, NP/Nasal REF",87070,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,35.57,7.34,38.68,,,,,,Acid-Fast Bacilli Stain REF,87206,0300,,55.2,41.4,41.4
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,44.26,5.63,72.8,,,,,,"Culture, Aerobic Bacteria REF",87077,0300,,171,128.25,128.25
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,84030,"Lab analysis to measure the phenylalanine, PKU (amino acid) level in blood specimen [HCPCS 84030]",102.6,76.95,76.95,18.18,4.62,77.09,,,,,,"Culture, Fungus W/Smear Not Hair, Skin, Blood REF",87106,0300,,152.2,114.15,114.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,79.1,7.58,134.6,,,,,,"Mycobacteria, Culture, w/ Fluorochrome Smear REF",87116,0300,,111.4,83.55,83.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,79.33,14.11,134.34,,,,,,"Culture, Sputum/Lower Respiratory REF",87070,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,85.85,9.87,141.2,,,,,,"Culture, Genital REF",87070,0300,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,82.52,12.64,85.85,,,,,,Cardiolipin Ab (IgA) REF,86147,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.63,6,88.2,,,,,,Cardiolipin Ab (IgG) REF,86147,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,41.53,2.7,54.33,,,,,,Cardiolipin Ab (IgM) REF,86147,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,46.33,5.26,76.2,,,,,,"Bile Acids, Fractionated And Ttl REF",83789,0300,,368.3,276.225,276.225
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,70.92,11.52,121.3,,,,,,Ca 19-9 REF,86301,0300,,134.5,100.875,100.875
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,86906,Lab blood analysis for Rh phenotyping to confirm the Rh antibody [HCPCS 86906],390.3,292.73,292.73,228.22,6.51,228.22,,,,,,"Vitamin D, 1,25 Dihydroxy REF",82652,0300,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,82.52,9.2,112.32,,,,,,Prealbumin REF,84134,0300,,239.3,179.475,179.475
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,60.37,7.24,496.86,,,,,,Hepatitis B Core Ab (IgM) REF,86705,0300,,130.1,97.575,97.575
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,63.18,2.84,108.1,,,,,,Tetanus Antitoxoid REF,86774,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,14.49,6.8,52.43,,,,,,Diphtheria Antitoxoid REF,86648,0300,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,94.54,8.17,155.5,,,,,,Von Willebrand Factor Ag REF,85246,0300,,199.6,149.7,149.7
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,94.54,29.48,155.5,,,,,,Scl-70 Ab REF,86235,0300,,272.4,204.3,204.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,94.54,29.48,155.5,,,,,,"Protein C, Ag REF",85302,0300,,328.6,246.45,246.45
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,100.56,45.82,378.9,,,,,,Alpha 2 Antiplasmin REF,85410,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,63.84,29.48,105,,,,,,"Platelet Ab, Direct, Flow Cytometry REF",86023,0300,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,247.4,40.24,406.9,,,,,,Maternal Serum AFP REF,82105,0300,,115.9,86.925,86.925
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,74.48,6.15,4344.87,,,,,,Thyroid Peroxidase Abs REF,86376,0300,,121.3,90.975,90.975
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,522.27,28.6,1161.38,,,,,,Antithrombin Iii Ag REF,85301,0300,,296.7,222.525,222.525
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,56.74,16.26,2475.42,,,,,,"Protein S Ag, Ttl REF",85305,0300,,281.2,210.9,210.9
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,121.36,29.4,2785.69,,,,,,"Von Willebrand Ag, Multimeric Analysis REF",85247,0300,,432.2,324.15,324.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,23.21,12.56,48.28,,,,,,"Drug Scrn, Comprehensive (Serum/Plasma) REF",80307,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,29.55,13.42,41.31,,,,,,"Bordetella Pertussis/ Parapertussis, Culture REF",87081,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,68.4,40.84,136.8,,,,,,"PSA, Ttl REF",84153,0300,,315.4,236.55,236.55
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,71.59,40.84,143.78,,,,,,Ammonia (P) REF,82140,0300,,137.9,103.425,103.425
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,221.92,140.59,428.4,,,,,,"Streptococcus, Group B Culture REF",87081,0300,,68.4,51.3,51.3
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,10.76,10.32,28.14,,,,,,Complement Comp C3 + C4 REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99195,Whole blood removal by needle to correct blood level imbalance [HCPCS 99195],175.4,131.55,131.55,106.64,73.48,115.98,,,,,,TRAB (TSH Receptor Binding Ab) REF,83520,0300,,151.1,113.325,113.325
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,Rabies Vaccine Response End Point Titer REF,86382,0300,,154.4,115.8,115.8
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,234.02,61.48,2109.82,,,,,,CA 15-3 REF,86316,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,346.62,50,3116.59,,,,,,"Chromium, Blood REF",82495,0300,,168.8,126.6,126.6
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,569.15,62.92,1098.7,,,,,,.CBC (Includes Diff/Plt) REF,85025,0300,,88.2,66.15,66.15
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,3.84,0.68,2868.2,,,,,,"Rickettsia (Rmsf) IgG,IgM w/Refl To Titers REF",86757,0300,,193,144.75,144.75
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,1.54,0.73,808.23,,,,,,"HSV 1/2 IgG,Type Specific Ab REF",86695,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,15.35,7.08,29.34,,,,,,"Lyme Disease Ab w/Refl To Blot (IgG, IgM) REF",86617,0300,,147.8,110.85,110.85
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,Lupus Anticoagulant Evaluation w/ Reflex REF,85613,0300,,161,120.75,120.75
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,32.22,2.66,76.2,,,,,,FSH And LH REF,,0300,,0,,
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.45,6.79,100.4,,,,,,Triple Scrn REF,82105,0300,,314.3,235.725,235.725
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,45.7,2.84,108.1,,,,,,"Cardiolipin Ab (IgA,IgG,IgM) REF",86147,0300,,116.9,87.675,87.675
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.72,7.27,172,,,,,,"Hsv 1/2 Ab (IgM), Ifa W/Rfl To Titer REF",,0300,,0,,
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,65.74,29.48,155.5,,,,,,Sm And Sm/RNP Abs REF,86235,0300,,226.1,169.575,169.575
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,65.74,29.48,155.5,,,,,,.Iron And Ttl Iron Binding Capacity REF,,0300,,0,,
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,66.29,4.51,1156.79,,,,,,Abo Group And Rh Type REF,86901,0300,,116.9,87.675,87.675
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,162.73,61.48,2109.82,,,,,,"Sjogren's Abs (SSA,SSB) REF",86235,0300,,220.5,165.375,165.375
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,10.57,0.68,2868.2,,,,,,Lymphocyte Subset Panel 4 REF,86360,0300,,519.4,389.55,389.55
"ALTERNATIVE INSURANCE RESOURCES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,10.57,0.73,808.23,,,,,,Creatinine Clearance REF,82575,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,0,35.11,337.46,,,,,,Direct LDL REF,83721,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,100.8,70.45,319.43,,,,,,Fructosamine REF,82985,0300,,110.3,82.725,82.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,0,107.28,315.01,,,,,,".Hcg, Ttl, Qn REF",84702,0300,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,Benzodiazepines By Gc/Ms REF,80346,0300,,248.2,186.15,186.15
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,EBV Viral Capsid Ag (Vca) Ab (IgM) REF,86665,0300,,151.1,113.325,113.325
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,0,214.38,2255.8,,,,,,"Hepatitis C Ab w/Refl To HCV RNA, Qn, PCR REF",86803,0300,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,0,55,166.67,,,,,,EBV Viral Capsid Ag (VCA) Ab (IgG) REF,86665,0300,,215.1,161.325,161.325
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,"Hepatitis B Surface Ab Immunity, Qn REF",86706,0300,,100.4,75.3,75.3
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,0,494.34,1384.62,,,,,,Cytomegalovirus Ab (IgM) REF,86645,0300,,122.5,91.875,91.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,0,137.3,1347.57,,,,,,EBV Nuclear Ag (Ebna) Ab (IgG) REF,86663,0300,,430,322.5,322.5
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,0,73.48,1221.85,,,,,,"Lyme Disease Abs (IgG,IgM), Immunoblot REF",86618,0300,,237.1,177.825,177.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,0,20.71,250.4,,,,,,"Escherichia Coli O157, Culture REF",,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72050,Spinal x-ray of upper spine (4 or 5 views) [HCPCS 72050],355,266.25,266.25,148.76,50.72,234.73,,,,,,"D-Dimer, Quantitative REF",85379,0300,,167.6,125.7,125.7
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,92.54,69.84,223.7,,,,,,Varicella Zoster Virus Ab (IgM) REF,86787,0300,,148.9,111.675,111.675
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,0,4.41,166.13,,,,,,Myeloperoxidase Ab REF,86021,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,0,166.13,1309.77,,,,,,Scrn For Staphylococcus Aureus REF,87081,0310,,99.3,74.475,74.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72192,"Pelvis CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 72192]",1221.6,916.2,916.2,0,511.9,1221.6,,,,,,"Cyclosporine A Trough, Blood REF",80158,0300,,389.3,291.975,291.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,0,94.25,222.4,,,,,,"Tissue Transglutaminase Ab, IgA REF",83516,0300,,176.4,132.3,132.3
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,18.85,18.85,148.78,,,,,,"PTH, Intact And Calcium REF",83970,0300,,135.2,101.4,101.4
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,0,30.08,220.5,,,,,,".Glucose, Random REF",82947,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73501,Hip x-ray of hip with pelvis (single view) [HCPCS 73501],225,168.75,168.75,49.24,49.24,127.42,,,,,,Banana (F92) IgE REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,37.7,37.7,213.75,,,,,,Clam (F207) IgE REF,86003,0300,,44.1,33.075,33.075
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,8.87,355.2,,,,,,Oyster (F290) IgE REF,86003,0300,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,0,11.25,148.9,,,,,,Parvovirus B19 Ab (IgG) REF,86747,0300,,188.6,141.45,141.45
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,0,2.66,76.2,,,,,,Parvovirus B19 Ab (IgM) REF,86747,0300,,188.6,141.45,141.45
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,0,1.89,53,,,,,,"Salmonella And Shigella, Culture REF",87449,0300,,54.5,40.875,40.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],137.9,103.43,103.43,0,14.81,137.9,,,,,,"Phosphatidylserine Ab (IgA,IgG,IgM) REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,0,5.44,96,,,,,,"HIV 1/2 Ag/Ab,Fourth Generation W/Rfl REF",87390,0300,,166.6,124.95,124.95
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,0,11.45,112.4,,,,,,Hs CRP REF,86141,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,0,2.66,8.7,,,,,,.Basic Metabolic Panel REF,80048,0300,,161,120.75,120.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,0,8.16,104.31,,,,,,"Epstein Barr Virus DNA, Qn Real Time PCR REF",87799,0300,,486.3,364.725,364.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,0,9.72,190.22,,,,,,.Comprehensive Metabolic Panel REF,80053,0300,,246,184.5,184.5
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,0,5.07,94.54,,,,,,Huntington Disease Mutation Analysis REF,81401,0300,,679.2,509.4,509.4
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,0,32.98,268.8,,,,,,Hepatic Function Panel REF,80076,0300,,185.3,138.975,138.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84145,Lab analysis to measure the procalcitonin (hormone) level in serum or plasma specimen [HCPCS 84145],398.1,298.58,298.58,0,27.66,265.89,,,,,,"Protein, Ttl And Protein Electrophoresis W/ Refl IFE REF",84155,0300,,134.5,100.875,100.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,54.52,7.58,134.6,,,,,,C3 Nephritic Factor (C3Nef) REF,86161,0300,,425.6,319.2,319.2
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,56.85,14.11,134.34,,,,,,Saccharomyces Cerevisiae Ab (Asca) (IgG) REF,86671,0300,,171,128.25,128.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,9.87,141.2,,,,,,Renal Function Panel REF,80069,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,0,6,88.2,,,,,,"Cytomegalovirus DNA, Qn, Real Time PCR REF",87497,0300,,466.5,349.875,349.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,0,8.55,182.7,,,,,,PAN ANCA Plus w/ Reflex REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,0,5.26,76.2,,,,,,"Campylobacter Jejuni Ab, Elisa REF",86625,0300,,296.7,222.525,222.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,0,6.74,92.02,,,,,,"Tissue Transglutaminase Ab, IgG,IgA REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,0,2.99,62.24,,,,,,Fibrin Monomer REF,85362,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,0,2.99,48.11,,,,,,Cyclic Citrullinated Peptide (Ccp) Ab (IgG) REF,86200,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,0,11.93,144.95,,,,,,Gliadin (Deamidated) Ab (IgA) REF,83516,0300,,162.2,121.65,121.65
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,0,6.79,100.4,,,,,,"Kappa/Lambda Light Chains Free w/ Ratio, Serum REF",83883,0300,,541.4,406.05,406.05
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,2.84,2.84,108.1,,,,,,Pepsinogen Ii REF,83519,0300,,347.4,260.55,260.55
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,0,6.8,52.43,,,,,,"Bk Virus DNA, Qn Real Time PCR, Plasma REF",87798,0300,,638.4,478.8,478.8
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,0,7.27,172,,,,,,"HCV RNA, Qn PCR w/Refl To Genotype, Lipa(R) REF",87522,0300,,325.3,243.975,243.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,10.26,6.15,4344.87,,,,,,"Chlamydia/N. Gonorrhoeae RNA, Tma, Urogenital REF",87491,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",296.7,222.53,222.53,24.86,24.86,180.39,,,,,,Bordetella Pertussis/ Parapertussis REF,87798,0300,,465.3,348.975,348.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,39.27,39.27,311.42,,,,,,Bv/Vaginitis Panel DNA Probe REF,87800,0300,,406.9,305.175,305.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,"Chromosome Analysis, Tissue REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,"Susceptibility, Aerobic Bacterium REF",,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,0,68.61,524.17,,,,,,"Helicobacter Pylori, Urea Breath Test REF",83013,0300,,309.9,232.425,232.425
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,0,20.72,3197.1,,,,,,Liver Kidney Microsome (Lkm-1) Ab (IgG) REF,86376,0300,,186.4,139.8,139.8
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,0,4.51,1156.79,,,,,,Actin (Smooth Muscle) Ab (IgG) REF,83516,0300,,116.9,87.675,87.675
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,"Clindamycin Resistance Test, (D Test) REF",87184,0300,,65.1,48.825,48.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,0,12.56,48.28,,,,,,Levetiracetam REF,80299,0300,,186.4,139.8,139.8
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,0,40.84,136.8,,,,,,Immune Cell Function REF,86353,0300,,620.8,465.6,465.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,200.21,140.59,241.75,,,,,,EBV Early Ag D Ab (IgG) REF,86663,0300,,165.4,124.05,124.05
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,100.8,70.45,319.43,,,,,,Allergen Specific IgE Mulberry Red Tree* REF,86003,0300,,29.9,22.425,22.425
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,90,39.1,434.06,,,,,,Penta Scrn REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,0,61.48,2109.82,,,,,,"Testosterone, Ttl, Ms REF",84403,0300,,240.4,180.3,180.3
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,0,50,3116.59,,,,,,Procalcitonin REF,84145,0300,,398.1,298.575,298.575
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,0,5.83,3301.98,,,,,,"Clostridium Difficile Toxin B,Ql Real Time PCR REF",87493,0300,,282.3,211.725,211.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,0,7.4,19.63,,,,,,Chromogranin A REF,86316,0300,,205.1,153.825,153.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0360,Hydralazine hcl injection [HCPCS J0360],36,27,27,0,6.88,317.84,,,,,,".Sureswab(R), Candidiasis, PCR REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,0,0.68,2868.2,,,,,,"Quantiferon(R) Tb Gold, (Draw Site Incubated) REF",86480,0300,,421.2,315.9,315.9
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0,0.73,808.23,,,,,,HLA-B51 Behcet'S Disease Association Test REF,81374,0300,,402.5,301.875,301.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,0,0.95,3583.7,,,,,,.Hemoglobin A1C w/ Eag REF,83036,0300,,115.9,86.925,86.925
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,0,1.66,23.47,,,,,,"Plasma Renin Activity, Lc/Ms/Ms REF",84244,0300,,143.4,107.55,107.55
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,1.76,23.48,,,,,,".Sureswab(R) Bacterial Vaginosis DNA, Qn, PCR REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,0,167.53,728.8,,,,,,Streptococcus Pneumoniae Ab IgG (23 Serotypes) REF,86317,0300,,"1,169.8",877.35,877.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,U0004,"2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r [HCPCS U0004]",89.3,66.98,66.98,0,39.29,43.47,,,,,,"HSV 1/2 IgG, w/Refl HSV2 Inhibition REF",86696,0300,,194.1,145.575,145.575
UNITED HEALTHCARE INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,0,35.11,337.46,,,,,,"17 Hydroxyprogesterone, Lc/Ms/Ms REF",83498,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,1.64,1.64,80.91,,,,,,"Aldosterone, Lc/Ms/Ms REF",82088,0300,,389.3,291.975,291.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],3533.3,2649.98,2649.98,8.8,8.8,16.21,,,,,,"Androstenedione, Lc/Ms/Ms REF",82157,0300,,340.8,255.6,255.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],5125.32,3843.99,3843.99,494.34,494.34,494.34,,,,,,Allergen Specific IgE Wingscale REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,195.09,192.01,343.2,,,,,,Giardia Ag w/Refl To Ova And Parasites REF,87329,0300,,186.4,139.8,139.8
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,246.4,168.37,416.16,,,,,,"Vitamin D,25-Oh,Ttl,Ia REF",82306,0300,,290.1,217.575,217.575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,49082,Abdominal cavity fluid drainage [HCPCS 49082],81.2,60.9,60.9,55,55,81.2,,,,,,RBC Fragility - Incubated REF,85557,0300,,118.1,88.575,88.575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],238.4,178.8,178.8,104.9,104.9,146.74,,,,,,Tricyclic Antidepressants Id And Quantitation REF,80336,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],446.3,334.73,334.73,196.37,196.37,196.37,,,,,,"Herpes Simplex/Varicella Zoster, Rapid Culture REF",87254,0300,,209.5,157.125,157.125
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,7.21,246,,,,,,"Liver Fibrosis, Fibrotest Actitest Panel REF",81596,0300,,414.4,310.8,310.8
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",31.5,23.63,23.63,13.86,13.86,33.1,,,,,,"Methicillin Resistant Staph Aureus, PCR REF",87641,0300,,309.9,232.425,232.425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],131.3,98.48,98.48,57.77,57.77,57.77,,,,,,"Bordetella pertussis toxin (PT) Antibodies (IgG, IgA), MAID REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],27.3,20.48,20.48,12.01,12.01,28.7,,,,,,Factor V HR2 Allele DNA Mutation Analysis REF,85220,0300,,283.4,212.55,212.55
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],41,30.75,30.75,18.04,18.04,43.1,,,,,,Factor V(Leiden) Mutation Analysis W/Rfl HR2 Mut REF,81241,0300,,615.2,461.4,461.4
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],41,30.75,30.75,18.04,18.04,43.1,,,,,,Prothrombin (Factor Ii) 20210G>A Mutation REF,81240,0300,,282.3,211.725,211.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],29.4,22.05,22.05,12.94,12.94,30.9,,,,,,"Methylenetetrahydrofolate Reductase (Mthfr), DNA REF",81291,0300,,425.6,319.2,319.2
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],38.9,29.18,29.18,17.12,17.12,40.9,,,,,,TPMT Activity REF,83789,0300,,654.9,491.175,491.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],112.4,84.3,84.3,49.46,49.46,49.46,,,,,,Musk Ab Test REF,83519,0300,,931.7,698.775,698.775
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],48.3,36.23,36.23,21.25,21.25,21.25,,,,,,"Carbamazepine, Free REF",80157,0300,,174.2,130.65,130.65
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],55.7,41.78,41.78,24.51,24.51,24.51,,,,,,"Bile Acids, Fractionated And Ttl, Pregnancy REF",83789,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],29.4,22.05,22.05,12.94,12.94,30.9,,,,,,"Metanephrines, Fract, Free, Lc/Ms/Ms, Plasma REF",83835,0300,,357.3,267.975,267.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],268.8,201.6,201.6,118.27,118.27,118.27,,,,,,".Sureswab(R) Trichomonas Vaginalis RNA, Ql, Tma REF",87661,0300,,200.7,150.525,150.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],31.5,23.63,23.63,13.86,13.86,33.1,,,,,,"Drug Abuse Panel 9, Serum REF",80307,0300,,329.7,247.275,247.275
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],38.9,29.18,29.18,17.12,17.12,40.9,,,,,,RNA Polymerase Iii Ab REF,83520,0300,,151.1,113.325,113.325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],27.3,20.48,20.48,12.01,12.01,28.7,,,,,,"Coccidioides Abs To Tp And F Ag, Id REF",86635,0300,,141.2,105.9,105.9
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],34.7,26.03,26.03,15.27,15.27,36.5,,,,,,"Aspergillus Abs,Id REF",86606,0300,,97.1,72.825,72.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],42,31.5,31.5,18.48,18.48,44.1,,,,,,IgF 2 REF,83789,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],129.2,96.9,96.9,56.85,17.07,101.94,,,,,,Mycoplasma Pneumoniae Ab (IgM) REF,86738,0300,,96,72,72
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",31.5,23.63,23.63,13.86,13.86,33.1,,,,,,Lamotrigine REF,80299,0300,,160,120,120
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],42,31.5,31.5,18.48,18.48,44.1,,,,,,"Protein, Ttl And Protein Electrophoresis w/ Immunofixation REF",84155,0300,,335.2,251.4,251.4
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],30.5,22.88,22.88,13.42,13.42,32.1,,,,,,Acetylcholine Receptor Modulating Ab REF,83519,0300,,317.6,238.2,238.2
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",84,63,63,36.96,5.31,66.28,,,,,,"Carbamazepine And Metabolite, Ttl REF",80156,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],182.7,137.03,137.03,80.39,10.35,80.39,,,,,,Marijuana Metabolites-20 Clinical Scrn/Confirm REF,80307,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],157.5,118.13,118.13,69.3,51.33,124.27,,,,,,Ca 125 REF,86304,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],31.5,23.63,23.63,13.86,13.86,13.86,,,,,,Dexamethasone REF,80299,0300,,174.2,130.65,130.65
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1323,992.25,992.25,582.12,582.12,1389.2,,,,,,Stone Analysis REF,82365,0300,,189.7,142.275,142.275
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],116.6,87.45,87.45,51.3,7.4,100.98,,,,,,"Shiga Toxins, EIA W/Rfl To E.Coli O157 Culture REF",87427,0300,,211.7,158.775,158.775
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",425.3,318.98,318.98,187.13,187.13,446.6,,,,,,"M.Tuberculosis Complex, PCR, Non Respiratory REF",87556,0300,,389.3,291.975,291.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.2,5.19,5.3,,,,,,Thyroglobulin Panel REF,84432,0300,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",301.4,226.05,226.05,132.62,132.62,231.48,,,,,,"Estradiol, Ultrasensitive Lc/Ms/Ms REF",82670,0300,,269.1,201.825,201.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",35.7,26.78,26.78,15.71,15.71,27.42,,,,,,Quad Scrn REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],5574.24,4180.68,4180.68,0,4398.09,4398.09,,,,,,"M.Tuberculosis Complex, PCR, Respiratory REF",87556,0300,,389.3,291.975,291.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],83.8,62.85,62.85,55,22.45,55,,,,,,"Drug Scrn Panel 9, Meconium REF",80307,0300,,225,168.75,168.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],23.1,17.33,17.33,10.16,10.16,17.74,,,,,,PSA (Free And Ttl) REF,84154,0300,,222.7,167.025,167.025
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,8.17,8.17,13.93,,,,,,"Candida Albicans Ab (IgG,IgA,IgM) REF",,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,1.1,1.1,1.1,,,,,,Cocaine Metabolites Clinical Scrn/Confirm REF,80307,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0.63,0.63,0.63,,,,,,Methadone Clinical Scrn/Confirm REF,80307,0300,,336.4,252.3,252.3
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,5.5,5.5,5.5,,,,,,Opiates Clinical Scrn/ Confirm REF,80307,0300,,776.2,582.15,582.15
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,4,4,8.64,,,,,,"Vdrl, Serum REF",86592,0300,,66.2,49.65,49.65
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.55,0.55,0.55,,,,,,TSI (Thyroid Stimulating Immunoglobulin) REF,83519,0300,,620.8,465.6,465.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J2997,Alteplase recombinant [HCPCS J2997],183.67,137.75,137.75,80.82,80.82,80.82,,,,,,Sex Hormone Binding Globulin REF,84270,0300,,194.1,145.575,145.575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,,Professional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,1710.43,1710.43,1710.43,,,,,,Topiramate REF,80201,0300,,131.3,98.475,98.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,2.09,2.09,3.53,,,,,,"Pregnenolone, Lc/Ms/Ms REF",84140,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,13.86,5.03,33.1,,,,,,"Bacterial ID, Aerobic REF",87086,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,56.63,19.16,56.63,,,,,,Measles Ab (IgM) REF,86765,0300,,169.8,127.35,127.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,18.04,18.04,43.1,,,,,,"T3, Free REF",84481,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,18.04,18.04,43.1,,,,,,Inhibin B REF,83520,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,12.94,4.42,42.84,,,,,,Acetylcholine Receptor Blocking Ab REF,83519,0300,,317.6,238.2,238.2
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,17.12,5.2,40.9,,,,,,Inhibin A REF,86336,0300,,283.4,212.55,212.55
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,19.4,3.99,48.28,,,,,,PTH-Related Protein (PTH-Rp) REF,83519,0300,,239.3,179.475,179.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,65.16,5.07,94.54,,,,,,Tryptase REF,83520,0300,,184.2,138.15,138.15
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,13.86,13.86,33.1,,,,,,"Amphetamines, Confirm. By Gc/Ms, Meconium REF",80359,0300,,188.6,141.45,141.45
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,22.18,4.75,40.9,,,,,,Lipoprotein (A) REF,83695,0300,,156.6,117.45,117.45
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,12.01,7.89,28.7,,,,,,Glutamic Acid Decarboxylase 65 Ab REF,83519,0300,,347.4,260.55,260.55
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,15.27,15.27,36.5,,,,,,Methylmalonic Acid REF,83921,0300,,393.7,295.275,295.275
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,18.48,18.48,44.1,,,,,,Cladosporium/Hormodendrum IgG4* REF,86001,0300,,97.1,72.825,72.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,13.86,4.35,39.58,,,,,,D Farinae Mite IgG4* REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,18.48,5.83,44.1,,,,,,Allergen Specific IgE Red Oak(Q.Rubra) REF,86003,0300,,47.5,35.625,35.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,13.42,4.02,32.1,,,,,,HIV 1 Genotype REF,87901,0300,,"1,153.3",864.975,864.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,582.12,105.86,1389.2,,,,,,Hemoglobinopathy Evaluation REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,69.04,4.51,1156.79,,,,,,"HCV RNA, Quantitative Real Time PCR REF",,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],230.5,172.88,172.88,245.74,80.15,262.94,,,,,,RPR (Dx) w/Refl Titer And Confirmatory Testing REF,86592,0300,,61.8,46.35,46.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,251.18,131.45,310.8,,,,,,"Testosterone, Free (Dialysis) And Ttl,Ms REF",84402,0300,,148.9,111.675,111.675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,266.1,266.1,323.65,,,,,,IA-2 Ab REF,,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,237.32,35.11,337.46,,,,,,Insulin AutoAb REF,86337,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,243.62,70.45,319.43,,,,,,B2 Glycoprotein I (IgA)Ab REF,86146,0300,,176.4,132.3,132.3
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,255.18,107.28,315.01,,,,,,B2 Glycoprotein I (IgM)Ab REF,86146,0300,,176.4,132.3,132.3
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,271.14,113,283.23,,,,,,B2 Glycoprotein I (IgG)Ab REF,86146,0300,,176.4,132.3,132.3
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],564.9,423.68,423.68,336.44,336.44,339.56,,,,,,Plasminogen Activator Inhibitor (Pai-1) REF,85415,0300,,202.9,152.175,152.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99306,Initial nursing facility visit by admitting physician for problem of high severity (typically 45 minutes per day) [HCPCS 99306],759.7,569.78,569.78,368,231.95,368,,,,,,"Cryoglobulin (%Cryocrit), Serum REF",82595,0300,,233.8,175.35,175.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,283.32,236.82,344.55,,,,,,Mumps Virus Ab (IgM) REF,86735,0300,,161,120.75,120.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,302.42,231.95,364.61,,,,,,Hepatitis E Ab (IgM) REF,86790,0300,,209.5,157.125,157.125
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],65.1,48.83,48.83,236.48,65.1,236.48,,,,,,"West Nile Virus Ab (IgG,IgM), Serum REF",86788,0300,,97.1,72.825,72.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99397,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (65 years of age and older) [HCPCS 99397],68.4,51.3,51.3,65.1,65.1,65.1,,,,,,Oxcarbazepine Metabolite REF,80339,0300,,134.5,100.875,100.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,G0438,"Ppps, initial visit [HCPCS G0438]",68.4,51.3,51.3,236.48,113,283.23,,,,,,"Direct Antiglobulin w/Refl Anti C3,Anti IgG REF",86880,0300,,54.1,40.575,40.575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2.75,0.68,2868.2,,,,,,"Insulin, Free (Bioactive) REF",83527,0300,,136.8,102.6,102.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,6.13,6.13,13.93,,,,,,"Sirolimus, Lc/Ms/Ms REF",80195,0300,,263.6,197.7,197.7
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,1.1,1.1,3.07,,,,,,Amiodarone REF,80299,0300,,189.7,142.275,142.275
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0.63,0.63,1.44,,,,,,Anca Vasculitides REF,86021,0300,,507.2,380.4,380.4
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,4,4,9.09,,,,,,Hsp 70 Ab (Anti 68 Kd Ag) REF,84181,0300,,389.3,291.975,291.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,J2997,Alteplase recombinant [HCPCS J2997],183.67,137.75,137.75,80.82,80.82,80.82,,,,,,Islet Cell Ab Scrn w/ Reflex To Titer REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,62.2,61.63,100.1,,,,,,Toxoplasma Ab (IgM) REF,86778,0300,,97.1,72.825,72.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,51701,Temporary bladder catheter insertion [HCPCS 51701],372.7,279.53,279.53,43.71,43.71,98.46,,,,,,"Cryptosporidium Ag, DFA REF",87328,0300,,136.8,102.6,102.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.09,2.07,19.9,,,,,,"Hepatitis C Viral RNA, Qualitative Tma REF",87521,0300,,390.3,292.725,292.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,9.92,1.28,46.3,,,,,,Rickettsial Disease Panel REF,,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,90662,Influenza vaccine for injection into muscle (preservation free) [HCPCS 90662],50,37.5,37.5,50,46.94,50,,,,,,"ANA Scr, IFA w/Refl Titer/Pattern/Lupus Panel 5 REF",83516,0300,,441,330.75,330.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.2,5.19,5.3,,,,,,"Norepinephrine, Plasma REF",82491,0300,,248.2,186.15,186.15
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,54.77,13.55,72.8,,,,,,"Rubella Abs (IgG, IgM) Diagnostic REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,89.05,62.38,245.75,,,,,,Hepatitis B Core Ab Ttl w/Refl IgM REF,86704,0300,,110.3,82.725,82.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,126.5,70,166.6,,,,,,TPMP Genotype REF,81401,0300,,653.9,490.425,490.425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,176.62,147.2,226.48,,,,,,"Hepatitis C Viral RNA Genotype, Lipa(R) REF",87902,0300,,620.8,465.6,465.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,Zonisamide REF,80299,0300,,277.9,208.425,208.425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.1,1.1,17.76,,,,,,21 Hydroxylase Ab REF,83516,0300,,171,128.25,128.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Dialysis Clinic,Institutional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2148.3,1611.23,1611.23,351.42,351.42,448,,,,,,Sm Ab REF,86235,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,351.42,214.38,2255.8,,,,,,"Opiates, Confirmation By Gc/Ms, Meconium REF",80307,0300,,776.2,582.15,582.15
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0151,"Hhcp-serv of pt,ea 15 min [HCPCS G0151]",50,37.5,37.5,30,30,30,,,,,,Catfish (F369) IgE ** REF,86003,0300,,50.8,38.1,38.1
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0157,Hhc pt assistant ea 15 [HCPCS G0157],50,37.5,37.5,30,30,30,,,,,,"HIV 1 RNA, Quantitative Real Time PCR REF",87536,0300,,488.5,366.375,366.375
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0162,"Hhc rn e&m plan svs, 15 min [HCPCS G0162]",75,56.25,56.25,45,45,45,,,,,,"Coccidioides Ab, Id w/Reflex To Cf REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0299,Hhs/hospice of rn ea 15 min [HCPCS G0299],75,56.25,56.25,45,45,45,,,,,,"Neisseria Gonorrhoeae RNA, TMA, Throat REF",87591,0300,,46.3,34.725,34.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0300,Hhs/hospice of lpn ea 15 min [HCPCS G0300],75,56.25,56.25,45,45,45,,,,,,Anca Scrn w/ Reflex To Titer REF,86021,0300,,"1,088.3",816.225,816.225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0493,Rn care ea 15 min hh/hospice [HCPCS G0493],150,112.5,112.5,90,90,90,,,,,,"Vitamin B1 (Thiamine), Serum/Plasma, Lc/Ms/Ms REF",84425,0300,,311,233.25,233.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0495,Rn care train/edu in hh [HCPCS G0495],75,56.25,56.25,45,45,45,,,,,,Hepatitis C Viral RNA Geno 1 Ns3 Drug Resist REF,87902,0300,,991.2,743.4,743.4
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Home Health,Institutional,Outpatient,G0496,Lpn care train/edu in hh [HCPCS G0496],150,112.5,112.5,45,45,45,,,,,,Lipoprotein Fractionation Ion Mobility REF,,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],132.3,99.23,99.23,0,43.81,43.81,,,,,,"Cardio Iq(R) Cholesterol, Ttl REF",,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,55,55,3102.09,,,,,,Cardio Iq(R) Triglycerides REF,,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,567.82,393.52,2894.06,,,,,,Cardio Iq(R) HDL Cholesterol REF,,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,11043,Skin and muscle removal (first 20 sq cm or less) [HCPCS 11043],2098.2,1573.65,1573.65,837.32,837.32,1391.28,,,,,,Cardio Iq(R) Apolipoprotein B REF,82172,0300,,43.1,32.325,32.325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,11045,Skin and tissue removal (each additional 20 sq cm) [HCPCS 11045],132.3,99.23,99.23,52.8,52.8,87.48,,,,,,Cardio Iq(R) Lipoprotein (A) REF,,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,11046,Skin and muscle removal (each additional 20 sq cm) [HCPCS 11046],282.3,211.73,211.73,112.64,112.64,188.55,,,,,,Cardio Iq(R) Hs CRP REF,86141,0300,,155.5,116.625,116.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,55,55,166.67,,,,,,"Platelet Ab, Indirect (IgG) REF",86022,0300,,389.3,291.975,291.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,12005,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (12.6 to 20.0 cm) [HCPCS 12005]",5144.3,3858.23,3858.23,55,55,55,,,,,,"BRCAvantage(R), Comprehensive REF",81162,0300,,"3,483.9",2612.925,2612.925
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,12006,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (20.1 to 30.0 cm) [HCPCS 12006]",689.32,516.99,516.99,55,55,55,,,,,,Gonadotropin Releasing Hormone REF,83727,0300,,402.5,301.875,301.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,55,55,125,,,,,,"Helicobacter Pylori, Urea Breath Test, Pediatric REF",83013,0300,,281.2,210.9,210.9
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,12013,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.6 to 5.0 cm) [HCPCS 12013]",469.98,352.49,352.49,55,55,111.73,,,,,,"Phospholipase A2 Receptor Abs, Serum REF",83520,0300,,551.3,413.475,413.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,12014,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (5.1 to 7.5 cm) [HCPCS 12014]",2113.8,1585.35,1585.35,55,55,55,,,,,,Cardio Iq(R) LP PLA2 Activity REF,,0300,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,13132,"Complex repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitalia, hands, and/or feet (2.6 to 7.5 cm) [HCPCS 13132]",615.02,461.27,461.27,55,55,55,,,,,,"Zika Virus RNA, Ql Real Time Rt PCR Panel, S/U REF",,0300,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,21014,Muscle tumor removal of face and scalp (2 cm or greater) [HCPCS 21014],5962.17,4471.63,4471.63,1793,1793,1793,,,,,,"Trypanosoma Cruzi Ab, IgG REF",86753,0300,,174.2,130.65,130.65
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,27252,Dislocated hip treatment with anesthesia (closed treatment) [HCPCS 27252],2428.44,1821.33,1821.33,59.97,59.97,59.97,,,,,,Liquid-Based ThinPrep Pap REF,88175,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,31500,Breathing tube insertion into windpipe cartilage with endoscope (emergent) [HCPCS 31500],567.9,425.93,425.93,237.95,237.95,666.54,,,,,,Liquid-Based ThinPrep Pap w/reflex HR HPV if ASCUS REF,,0310,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,8.8,2.44,580.94,,,,,,Liquid-Based ThinPrep Pap w/High Risk (HR) HPV REF,,0310,,0,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,494.34,494.34,1384.62,,,,,,Liquid-Based ThinPrep Pap w/reflex HR HPV if ASCUS+16/18/45 REF,87624,0310,,35.3,26.475,26.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,36600,Collection of blood specimen from arterial puncture for diagnosis [HCPCS 36600],293.6,220.2,220.2,123.02,39.78,171.67,,,,,,Liquid-Based ThinPrep Pap w/High Risk (HR) HPV+16/18/45 REF,87624,0310,,35.3,26.475,26.475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],4605.38,3454.04,3454.04,250,15.34,2509.37,,,,,,Urine Cytology REF,88108,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],4243.39,3182.54,3182.54,1309.4,246.83,3309.99,,,,,,Fine Needle Aspiration REF,88173,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,47562,Gallbladder removal with an endoscope [HCPCS 47562],8595.17,6446.38,6446.38,390,390,1272.13,,,,,,Sputum Cytology REF,88108,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,49082,Abdominal cavity fluid drainage [HCPCS 49082],2166.3,1624.73,1624.73,55,55,70.35,,,,,,"Fluid Cytology, Other REF",88108,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,49505,Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505],10239.44,7679.58,7679.58,390,390,3515.07,,,,,,Breast Biopsy REF,,0310,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,125.97,119.94,617.26,,,,,,GI Biopsy #1 REF,99000,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,56405,Female genitals abscess incision and drainage [HCPCS 56405],14398.12,10798.59,10798.59,11.57,11.57,11.57,,,,,,Gynecologic Biopsy #1 REF,88305,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70120,Mastoid bone (bone behind ear) x-ray (less than 3 views per side) [HCPCS 70120],243.7,182.78,182.78,102.12,102.12,102.12,,,,,,Skin Biopsy #1 REF,88305,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70220,"Paranasal sinuses x-ray usually including 4 to 5 standard views of the skull (complete study, miniumum of 3 views) [HCPCS 70220]",225,168.75,168.75,94.25,94.25,94.25,,,,,,Immunofloresence REF,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70360,Neck x-ray to examine soft tissue for any obstructions and/or foreign bodies within the throat or neck [HCPCS 70360],225,168.75,168.75,94.25,94.25,182.07,,,,,,"Biopsy,other,(NOS) REF",,0310,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,658.81,137.3,1347.57,,,,,,Nasal Biopsy REF,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,550.26,73.48,1221.85,,,,,,Products of Conception (POC) REF,88305,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70491,"Neck CT scan of the soft tissue of the neck with contrast to examine injury, foreign bodies, or tumors [HCPCS 70491]",1319.8,989.85,989.85,553.04,272.21,553.04,,,,,,High-risk HPV REF,87624,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70496,CTA scan of head blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70496],1345.1,1008.83,1008.83,563.64,563.64,889.41,,,,,,Appendix REF,88304,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,70498,CTA scan of neck blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70498],1345.1,1008.83,1008.83,563.64,294.63,889.41,,,,,,Surgical Procedure #1 REF,88302,0310,,33.1,24.825,24.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,104.9,20.71,250.4,,,,,,FSI DTA,87209,0300,,56.8,42.6,42.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,113.65,28.74,271.3,,,,,,99999-9999-01 - DO NOT USE DEXTROSE [REEV],,0250,99999-9999-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,94.25,94.25,177.23,,,,,,99999-9999-02 - DO NOT USE DOPAMINE [REEV],,0250,99999-9999-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,109.96,109.96,166.13,,,,,,99999-9999-03 - DO NOT USE LIDOCAINE [REEV],,0250,99999-9999-03,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71110,Rib cage x-ray of ribs on both sides of body (3 views) [HCPCS 71110],236,177,177,103.84,103.84,166.13,,,,,,99999-9999-04 - DO NOT USE STERILE WATER [REEV],,0250,99999-9999-04,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,554.4,137.3,1124.55,,,,,,99999-9999-05 - DO NOT USE MAGNESIUM SULFATE [REEV],,0250,99999-9999-05,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,591.84,272.21,1200.54,,,,,,99999-9999-06 - DO NOT USE MAGNESIUM SULFATE 40 GM [REEV],,0250,99999-9999-06,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71270,"Chest CT scan without contrast, followed by contrast to examine injury, foreign bodies, or tumors [HCPCS 71270]",1572.2,1179.15,1179.15,658.81,658.81,658.81,,,,,,ROOM/BED: Swing Bed with Telemetry,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1412.4,1059.3,1059.3,563.64,272.21,898.39,,,,,,ROOM/BED: Direct Admit,G0379,0762,,24.3,18.225,18.225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,94.25,4.45,148.78,,,,,,ROOM/BED: OB,,0112,,581.1,435.825,435.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72050,Spinal x-ray of upper spine (4 or 5 views) [HCPCS 72050],355,266.25,266.25,148.76,50.72,234.73,,,,,,ROOM/BED: NB,,0171,,325.3,243.975,243.975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],246,184.5,184.5,107.22,107.22,162.99,,,,,,ROOM/BED: Private with Telemetry,,0110,,714.5,535.875,535.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72072,Spinal x-ray of middle spine (3 views) [HCPCS 72072],249.2,186.9,186.9,104.41,104.41,104.41,,,,,,ROOM/BED: Private without Telemetry,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,94.25,69.84,223.7,,,,,,ROOM/BED: Isolation,,0164,,581.1,435.825,435.825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,94.25,4.41,166.13,,,,,,99999-9999-07 - DO NOT USE SODIUM CHLORIDE [REEV],,0250,99999-9999-07,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,546.08,166.13,1107.72,,,,,,99999-9999-08 - DO NOT USE NICARDIPINE [REEV],,0250,99999-9999-08,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,554.4,166.13,1309.77,,,,,,99999-9999-09 - DO NOT USE NITROGLYCERIN [REEV],,0250,99999-9999-09,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72141,Imaging of upper spinal canal by MRI without contrast [HCPCS 72141],1046.4,784.8,784.8,438.46,438.46,588.71,,,,,,68084-0107-01 - acyclovir 200 mg Cap [REEV],,0250,68084-0107-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72146,Imaging of middle spinal canal by MRI without contrast [HCPCS 72146],1046.4,784.8,784.8,438.46,438.46,438.46,,,,,,63739-0410-10 - allopurinol 100 mg Tab [REEV],,0250,63739-0410-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,438.46,350.85,825.61,,,,,,00904-6370-61 - amLODIPine 5 mg Tab [REEV],,0250,00904-6370-61,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72157,"Imaging of middle spinal canal by MRI without contrast, followed by contrast [HCPCS 72157]",1974.7,1481.03,1481.03,827.46,827.46,827.46,,,,,,66685-1002-02 - amoxicillin-clavulanate 500 mg-125 mg Tab [REEV],,0250,66685-1002-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72158,"Imaging of lower spinal canal by MRI without contrast, followed by contrast [HCPCS 72158]",1974.7,1481.03,1481.03,827.46,827.46,827.46,,,,,,51079-0759-20 - atenolol 25 mg Tab [REEV],,0250,51079-0759-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],98.2,73.65,73.65,41.14,41.14,166.13,,,,,,68084-0099-01 - atorvastatin 40 mg Tab [REEV],,0250,68084-0099-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72192,"Pelvis CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 72192]",1221.6,916.2,916.2,511.9,511.9,1221.6,,,,,,69452-0143-20 - benzonatate 100 mg Cap [REEV],,0250,69452-0143-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,72220,X-ray of sacrum and tailbone (minimum of 2 views) [HCPCS 72220],225,168.75,168.75,94.25,94.25,148.93,,,,,,51079-0145-20 - benazepril 10 mg Tab [REEV],,0250,51079-0145-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73010,Shoulder blade x-ray complete study [HCPCS 73010],225,168.75,168.75,94.25,94.25,94.25,,,,,,16729-0200-01 - busPIRone 5 mg Tab [REEV],,0250,16729-0200-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73020,Shoulder x-ray (single view) [HCPCS 73020],225,168.75,168.75,98.01,98.01,123.34,,,,,,64380-0723-06 - calcitriol 0.25 mcg Oral Cap [REEV],,0250,64380-0723-06,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,94.25,94.25,222.4,,,,,,51079-0931-20 - carvedilol 12.5 mg Tab [REEV],,0250,51079-0931-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],225,168.75,168.75,98.01,27.4,191.25,,,,,,62756-0457-88 - carbidopa-levodopa 50 mg-200 mg ER Tab [REEV],,0250,62756-0457-88,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,94.25,25.73,191.25,,,,,,68084-0976-01 - celecoxib 200 mg Cap [REEV],,0250,68084-0976-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",225,168.75,168.75,94.25,94.25,180,,,,,,50268-0151-15 - cephalexin 250 mg Cap [REEV],,0250,50268-0151-15,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,94.25,24.39,148.78,,,,,,60687-0317-25 - chlorthalidone 25 mg Tab [REEV],,0250,60687-0317-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,94.25,18.85,148.78,,,,,,55111-0127-01 - ciprofloxacin 500 mg Tab [REEV],,0250,55111-0127-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,99,33.08,182.07,,,,,,68084-0651-25 - clarithromycin 500 mg Tab [REEV],,0250,68084-0651-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,99,99,166.13,,,,,,00143-9786-10 - enalapril 1.25 mg/mL Sol 2ml [REEV],J3490,0250,00143-9786-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,94.25,30.08,220.5,,,,,,68382-0096-01 - hydroxychloroquine 200 mg Tab [REEV],,0250,68382-0096-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,94.25,94.25,191.25,,,,,,51079-0118-20 - dicyclomine 10 mg Cap [REEV],,0250,51079-0118-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73501,Hip x-ray of hip with pelvis (single view) [HCPCS 73501],225,168.75,168.75,94.25,49.24,127.42,,,,,,00904-5921-61 - digoxin 125 mcg (0.125 mg) Tab [REEV],,0250,00904-5921-61,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,94.25,57.76,225,,,,,,60687-0292-01 - donepezil 5 mg Tab [REEV],,0250,60687-0292-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],225,168.75,168.75,94.25,35.41,222.75,,,,,,00378-3125-01 - doxepin 25 mg Cap [REEV],,0250,00378-3125-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73551,Thighbone x-ray (single view) [HCPCS 73551],225,168.75,168.75,94.25,94.25,225,,,,,,69238-1100-02 - doxycycline hyclate 100 mg Cap [REEV],,0250,69238-1100-02,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],225,168.75,168.75,94.25,94.25,225,,,,,,00904-6453-61 - DULoxetine 30 mg Cap [REEV],,0250,00904-6453-61,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,94.25,29.4,177.53,,,,,,42806-0549-30 - dutasteride 0.5 mg Cap [REEV],,0250,42806-0549-30,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,94.25,94.25,214.2,,,,,,68084-0391-01 - enalapril 10 mg Tab [REEV],,0250,68084-0391-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73565,"Knee x-ray of both knees, standing (front to back view) [HCPCS 73565]",236,177,177,101.77,101.77,123.34,,,,,,00904-6426-61 - escitalopram 10 mg Tab [REEV],,0250,00904-6426-61,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],225,168.75,168.75,94.25,27.06,225,,,,,,63739-0645-10 - famotidine 20 mg Tab [REEV],,0250,63739-0645-10,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,94.25,94.25,191.25,,,,,,68084-0762-01 - gabapentin 300 mg Cap [REEV],,0250,68084-0762-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,94.25,69.84,225,,,,,,00781-1392-01 - haloperidol 1 mg Tab [REEV],,0250,00781-1392-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,94.25,56.37,178.99,,,,,,68084-0253-01 - hydrOXYzine hydrochloride 10 mg Tab [REEV],,0250,68084-0253-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,94.25,37.7,213.75,,,,,,51079-0077-20 - hydrOXYzine pamoate 25 mg Cap [REEV],J1050,0250,51079-0077-20,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],225,168.75,168.75,94.25,94.25,148.78,,,,,,63323-0485-27 - lidocaine 1% Sol [REEV],J2001,0250,63323-0485-27,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",694.6,520.95,520.95,299.82,166.13,526.22,,,,,,25021-0701-01 - ketorolac 30 mg/mL Sol [REEV],J1885,0250,25021-0701-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],1046.4,784.8,784.8,438.46,350.85,636.21,,,,,,60687-0114-01 - labetalol 100 mg Tab [REEV],,0250,60687-0114-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,94.25,90,225,,,,,,68084-0764-25 - potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab [REEV],,0250,68084-0764-25,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,94.25,31.41,166.13,,,,,,68084-0300-21 - dantrolene 25 mg Cap [REEV],,0250,68084-0300-21,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,74022,"Abdominal x-ray, complete study including 2 or more views of abdomen and single view of chest [HCPCS 74022]",377.1,282.83,282.83,158,158,229.27,,,,,,60687-0118-21 - doxycycline hyclate 100 mg Cap [REEV],,0250,60687-0118-21,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,74170,"Abdominal CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74170]",1572.2,1179.15,1179.15,658.81,658.81,723.21,,,,,,68084-0157-01 - morphine ER 15 mg tab [REEV],,0250,68084-0157-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1043.2,180.22,3324.06,,,,,,50268-0337-15 - fluconazole 100 mg Tab [REEV],,0250,50268-0337-15,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1052,561.23,2500,,,,,,00904-6575-61 - PHENobarbital 32.4 mg Tab [REEV],,0250,00904-6575-61,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",4712.1,3534.08,3534.08,1315.78,561.23,2284.78,,,,,,55111-0352-60 - rivastigmine 1.5 mg Cap [REEV],,0250,55111-0352-60,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,176.48,166.13,421.2,,,,,,00185-0055-01 - metolazone 5 mg Tab [REEV],,0250,00185-0055-01,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,135.39,62.12,274.64,,,,,,50383-0804-16 - codeine-promethazine 10 mg-6.25 mg/5 mL Syr [REEV],,0250,50383-0804-16,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,273.99,166.13,529.3,,,,,,99999-9999-99 - Template Non-Formulary [REEV],,0250,99999-9999-99,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,196.37,137.3,401.67,,,,,,93005 EKG ROUTINE CHARGE,93005,0730,,122.5,91.875,91.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,273.99,107.93,965.26,,,,,,93225 HOLTER MONITOR HOOK UP CHARGE,93225,0731,,296.7,222.525,222.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,281.38,166.13,529.81,,,,,,36600 ARTERIAL PUNCTURE CHARGE,36600,0410,,293.6,220.2,220.2
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,235.18,166.13,1065.48,,,,,,82800 BLOOD PH ONLY CHARGE,82800,0300,,94.9,71.175,71.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",468.7,351.53,351.53,196.37,166.13,311.42,,,,,,94375 FLOW VOLUME LOOP CHARGE,94375,0460,,134.5,100.875,100.875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76870,Imaging of scrotum by ultrasound [HCPCS 76870],468.7,351.53,351.53,196.37,166.13,309.92,,,,,,92950 CPR CHARGE,92950,0480,,171,128.25,128.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76881,Arm or leg ultrasound (complete) [HCPCS 76881],465.3,348.98,348.98,180.66,180.66,366.52,,,,,,94002 CONT. VENTILATION-1ST CHARGE,94002,0410,,758.6,568.95,568.95
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],309.9,232.43,232.43,22.66,22.66,204.92,,,,,,94003 CONT VENT-SUBSEQUENT DAY CHARGE,94003,0410,,758.6,568.95,568.95
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,0,23.61,157.86,,,,,,94010 PFT CHARGE,94010,0460,,261.4,196.05,196.05
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],485.7,364.28,364.28,203.5,84.74,462.5,,,,,,94664 INITIAL SVN TREATMENT CHARGE,94664,0410,,83.8,62.85,62.85
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,203.5,108.36,412.85,,,,,,94760 PULSE OXIMETRY SINGLE CHARGE,94760,0460,,56.3,42.225,42.225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,93.2,89.59,349.41,,,,,,94761 PULSE OXIMETRY MULTIPLE CHARGE,94761,0460,,112.5,84.375,84.375
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80047,"Lab analysis to measure the amount of ionized calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80047]",161,120.75,120.75,67.45,13.95,94.13,,,,,,94668 PD/ PERE SUBSEQUENT CHARGE,94668,0410,,83.8,62.85,62.85
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,67.45,8.49,161,,,,,,90471 IMMUNIZATION ADMIN VAC INITIAL CHARGE,90471,0771,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,0,41.68,551.29,,,,,,90472 IMMUNIZATION ADMIN VAC EA ADDITIONAL CHARGE,90472,0771,,69.6,52.2,52.2
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,8.87,355.2,,,,,,96360 IV HYDRATION INITIAL CHARGE,96360,0260,,355,266.25,266.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,62.39,11.25,148.9,,,,,,96361 IV HYDRATION ADDITIONAL CHARGE,96361,0260,,77.2,57.9,57.9
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],131.3,98.48,98.48,55,55,99.65,,,,,,96365 IV HYDRATION TH/DX INITIAL CHARGE,96365,0260,,355,266.25,266.25
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,193.6,48.41,364.52,,,,,,96366 IV INFUSION TH/PR/DX FIRST HOUR CHARGE,96366,0260,,77.2,57.9,57.9
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,77.62,8.3,183.45,,,,,,96367IV INFUSION TH/PR/DX EACH ADD HOUR CHARGE,96367,0260,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80162,Lab analysis to measure the amount of total digoxin in blood specimen [HCPCS 80162],107,80.25,80.25,44.84,44.84,44.84,,,,,,96368 IV INFUSION TH/PR/DX CONCURENT CHARGE,96368,0260,,92.7,69.525,69.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80164,Lab analysis to measure the amount of total valproic acid in blood specimen [HCPCS 80164],116.9,87.68,87.68,13.54,13.54,103.93,,,,,,O and P Source QST,87177,0300,,56.8,42.6,42.6
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],99.3,74.48,74.48,13.25,13.12,94.5,,,,,,SN FREE TEXT ITEM,,0278,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80197,Lab analysis to measure the amount of tacrolimus in blood specimen [HCPCS 80197],389.3,291.98,291.98,163.11,163.11,257.41,,,,,,ADD A SLEEVE,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80202,Lab analysis to measure the amount of vancomycin (antibiotic) in serum specimen [HCPCS 80202],158.8,119.1,119.1,66.53,66.53,120.28,,,,,,AIRWAY LARGE SIZE 100,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,124.74,14.4,297.7,,,,,,AIRWAY LARGE SIZE 90,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,37.09,9.42,73.71,,,,,,AIRWAY MEDIUM SIZE 70,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,55,9.63,285.09,,,,,,AIRWAY MEDIUM SIZE 80,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,31.9,2.66,76.2,,,,,,AIRWAY SMALL SIZE 50,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,22.18,1.89,53,,,,,,AIRWAY SMALL SIZE 60,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,81005,Lab analysis of urine specimen without immunoassays [HCPCS 81005],111.4,83.55,83.55,2.17,2.17,83.71,,,,,,AIRWAYS SMALL SIZE 40,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,34.19,6.2,81.6,,,,,,ALLEVYN 4X4 HYDRO/DRESSING FOAM,,0272,,11.25,8.4375,8.4375
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82024,Lab analysis to measure the adrenocorticotropic hormone (ACTH) level [HCPCS 82024],362.8,272.1,272.1,152.02,152.02,362.8,,,,,,AMNIO-HOOK,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,11.09,2.31,20.91,,,,,,"ANCHOR, ENDO",,0270,,357.59,268.1925,268.1925
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],314.3,235.73,235.73,58.21,14.09,91.91,,,,,,"ANESTHESIA, CIRCUIT-PEDI",,0270,,12.58,9.435,9.435
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],137.9,103.43,103.43,57.77,14.81,137.9,,,,,,ANKLE BRACE MED LEFT,,0270,,19.73,14.7975,14.7975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,40.22,5.44,96,,,,,,ANKLE BRACE LG,,0270,,19.73,14.7975,14.7975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82164,Lab analysis to measure the angiotensin l - converting enzyme (ACE) level [HCPCS 82164],101.5,76.13,76.13,42.5,42.5,42.5,,,,,,ANKLE SUPPORT MED NEOP,,0270,,19.73,14.7975,14.7975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82175,Lab analysis to measure the arsenic level in urine specimen [HCPCS 82175],226.1,169.58,169.58,94.73,94.73,94.73,,,,,,ANKLE SUPPORT XLG NEOP,,0270,,19.73,14.7975,14.7975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],118.1,88.58,88.58,49.46,4.22,71.8,,,,,,ANKLE SUPPORT SM,,0270,,19.73,14.7975,14.7975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],30.9,23.18,23.18,12.94,12.94,18.79,,,,,,"ANKLE, SUPPORT SM EXCELLATOR 2002",,0270,,30.89,23.1675,23.1675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,20.42,16.18,45.86,,,,,,ANKLE SUPPORT REG EXCELLATOR 2001,,0270,,5.74,4.305,4.305
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,121.53,30.08,290.1,,,,,,ANOSCOPE,,0270,,8.17,6.1275,6.1275
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,56.63,19.16,56.63,,,,,,ARMBOARD GREEN 18,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82378,Lab analysis to measure the carcinoembryonic antigen (cea) protein level [HCPCS 82378],202.9,152.18,152.18,85.01,85.01,123.36,,,,,,ARMBOARD 9,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82384,Lab analysis to measure the catecholamines (organic nitrogen) level (fractionated) [HCPCS 82384],275.7,206.78,206.78,25.25,25.25,25.25,,,,,,ARMBOARD CHILD/INFANT GREEN FOAM,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82390,Lab analysis to measure the ceruloplasmin (protein) level [HCPCS 82390],69.6,52.2,52.2,29.13,29.13,29.13,,,,,,ARMBOARD INFANT,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82530,Lab analysis to measure the amount of free cortisol (hormone) [HCPCS 82530],237.1,177.83,177.83,16.71,16.71,233.8,,,,,,ASPIRATION BIOPSY NEEDLE 18G,,0272,,30.37,22.7775,22.7775
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82533,Lab analysis to measure the amount of total cortisol (hormone) [HCPCS 82533],135.7,101.78,101.78,56.85,16.56,56.85,,,,,,ASPIRATOR MECONIUM,,0272,,13.26,9.945,9.945
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,27.28,5.81,65.1,,,,,,ATTEST M1261P,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,41.58,11.55,98.31,,,,,,BAG AMBU PEDI,,0270,,24.69,18.5175,18.5175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,17.12,5.2,40.9,,,,,,BAG BILE REG,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,40.66,4.35,81.23,,,,,,BAG AMBER BABY BLUE (INFANT),,0270,,24.57,18.4275,18.4275
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,52.23,12.67,98.39,,,,,,BAG AMBER NEONATE,,0270,,46.48,34.86,34.86
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,194.96,32.34,465.3,,,,,,BAG AMBU W/PEEP VALVE,,0270,,20.65,15.4875,15.4875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],480.7,360.53,360.53,100.72,28.4,180.6,,,,,,BAG HYPERINFLATION,,0270,,30.73,23.0475,23.0475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,49.46,11.45,112.4,,,,,,BAG OSTOMY SIZE 1 1/2,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,102.12,14.94,192.28,,,,,,BAG OSTOMY SIZE 2,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82785,Lab analysis to measure the IgE (immune system protein) level [HCPCS 82785],135.7,101.78,101.78,56.85,16.51,56.85,,,,,,BAG OSTOMY SIZE 2 1/2,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82803,Lab analysis to measure the amount of blood gases [HCPCS 82803],293.3,219.98,219.98,98.43,26.5,223.7,,,,,,BAG OSTOMY SIZE 3,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,3.83,2.66,8.7,,,,,,BAG URINARY DRAIN,,0270,,11.5,8.625,8.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,82977,Lab analysis to measure the glutamyltransferase (liver enzyme) level [HCPCS 82977],65.1,48.83,48.83,25.96,11.93,52.08,,,,,,BAG URINARY(900ml) LEG,,0270,,5.69,4.2675,4.2675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83003,Lab analysis to measure the human growth hormone level in amniotic fluid specimen [HCPCS 83003],135.7,101.78,101.78,56.85,27.64,56.85,,,,,,CUFF SOFT-BLOOD LARGE ADULT 2-TUBE SCREW,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83010,Lab analysis to measure the haptoglobin (serum protein) level in serum specimen [HCPCS 83010],134.5,100.88,100.88,56.36,56.36,56.36,,,,,,GOLD DUST SUPER ABSORBENT WOUND FILLER,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,129.84,56.58,188.42,,,,,,BANDAGE ACE ELASTIC 2,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,48.53,8.16,104.31,,,,,,BANDAGE ACE ELASTIC 4,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,184.8,11.58,453.2,,,,,,BANDAGE ACE ELASTIC 6,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83519,Lab analysis to measure the amount of substance by radioimmunoassay [HCPCS 83519],931.7,698.78,698.78,100.28,15.46,100.28,,,,,,BANDAGE ACE ELASTIC 3,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,21.25,5.43,33.59,,,,,,BANDAGE HONEYCOMB 4,,0270,,6.19,4.6425,4.6425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,24.51,7.34,38.68,,,,,,BANDAGE HONEYCOMB 6,,0270,,9.04,6.78,6.78
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,81.31,9.72,190.22,,,,,,BANDAGE KERLIX 2,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,65.16,5.07,94.54,,,,,,BANDAGE KERLIX 6,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83655,Lab analysis to measure the lead level in blood specimen [HCPCS 83655],123.5,92.63,92.63,51.74,12.31,122.26,,,,,,BANDAGE KLING 2 (CARDINAL),,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,44.35,5,105.9,,,,,,BANDAGE KLING 4,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,30.49,5.63,72.8,,,,,,BANDAGE KLING 6 (CARDINAL),,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83825,Lab analysis to measure the mercury level in blood specimen [HCPCS 83825],233.8,175.35,175.35,97.94,97.94,97.94,,,,,,BANDAGE STERI STRIPS 1/4,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83835,Lab analysis to measure the metanephrines level in urine specimen [HCPCS 83835],409.1,306.83,306.83,16.94,16.94,287.91,,,,,,BANDAGE STERISTRIPS 1,,0272,,6.39,4.7925,4.7925
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,118.27,32.98,268.8,,,,,,BANDAGE STERI STRIPS 1/2,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,56.63,41.96,133.85,,,,,,BANDAGE STERI STRIPS 1/8,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,22.18,4.75,40.9,,,,,,BANDAGE UNNA BOOT 4 X 10,,0272,,16.48,12.36,12.36
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,12.01,7.89,28.7,,,,,,BASIN EMESIS,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84134,Lab analysis to measure the prealbumin (protein) level in urine specimen [HCPCS 84134],239.3,179.48,179.48,100.28,24.19,158.23,,,,,,BASIN WASH,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84145,Lab analysis to measure the procalcitonin (hormone) level in serum or plasma specimen [HCPCS 84145],398.1,298.58,298.58,166.8,27.66,265.89,,,,,,BATH SITZ,,0270,,6.51,4.8825,4.8825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,77.62,19.44,112.66,,,,,,BELT RIB MEN,,0270,,23.45,17.5875,17.5875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,132.13,18.45,315.4,,,,,,BELT RIB WOMEN,,0270,,15.72,11.79,11.79
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84154,Lab analysis to measure the amount of free PSA (prostate specific antigen) in serum specimen [HCPCS 84154],222.7,167.03,167.03,93.32,93.32,135.4,,,,,,BELT RIB XL MEN,,0270,,13.8,10.35,10.35
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,15.27,15.27,36.5,,,,,,HOLDER ET TUBE,,0270,,18.3,13.725,13.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,24.51,3.73,46.16,,,,,,BINDER ABDOMINAL,,0270,,16.53,12.3975,12.3975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84165,Lab analysis to measure the amount of protein in serum specimen [HCPCS 84165],186.4,139.8,139.8,78.1,78.1,124.5,,,,,,BLADE KNIFE 11,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84166,Lab analysis to measure the amount of protein in body fluid specimen [HCPCS 84166],233.8,175.35,175.35,97.94,17.83,229.12,,,,,,BLADE KNIFE 12,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84425,Lab analysis to measure the vitamin B-1 (thiamine) level in blood specimen [HCPCS 84425],311,233.25,233.25,130.28,130.28,245.38,,,,,,HOOK DISECTING SYNERGY HS,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84432,Lab analysis to measure the thyroglobulin (thyroid related hormone) level in serum specimen [HCPCS 84432],92.7,69.53,69.53,38.81,38.81,38.81,,,,,,BLADE CURVED 5MM DIAMETER 32CM,,0270,,242.9,182.175,182.175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],61.8,46.35,46.35,25.87,11.39,37.57,,,,,,BLADE CLIPPER,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,54.52,7.58,134.6,,,,,,BLADE KNIFE SZ 10,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,56.85,14.11,134.34,,,,,,BLADE KNIFE SZ 15,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,18.48,5.83,44.1,,,,,,BLADE KNIFE SZ 20,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84479,Lab analysis to evaluate thyroid hormone in serum specimen [HCPCS 84479],61.8,46.35,46.35,25.87,7.26,25.87,,,,,,CUFF BLOOD PRESS SZ 1,,0270,,14.74,11.055,11.055
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,65.16,14.41,153.94,,,,,,CUFF BLOOD PRESS SZ 2,,0270,,14.74,11.055,11.055
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",233.8,175.35,175.35,97.94,17.22,200.91,,,,,,CUFF BLOOD PRESS SZ 3,,0270,,14.74,11.055,11.055
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,59.14,9.87,141.2,,,,,,BLOOD Y-TYPE,,0270,,15.82,11.865,11.865
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84512,Lab analysis to identify troponin (protein) in plasma specimen [HCPCS 84512],174.2,130.65,130.65,73,10.26,73,,,,,,BOOT BUCKS TRACTION (LARGE),,0270,,37.06,27.795,27.795
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,13.42,4.02,32.1,,,,,,BOOT TRACTION BUCKS (MEDIUM),,0270,,37.06,27.795,27.795
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,22.18,4.54,50.4,,,,,,BOOT WALKING-LG,,0270,,72.49,54.3675,54.3675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84630,"Lab analysis to measure the zinc level in blood, serum, or urine specimen [HCPCS 84630]",135.7,101.78,101.78,56.85,56.85,56.85,,,,,,BOOT WALKING-MED,,0270,,72.82,54.615,54.615
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,81.8,17.05,191.3,,,,,,BOOT WALKING-SM,,0270,,73.02,54.765,54.765
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],44.1,33.08,33.08,4.18,2.41,10,,,,,,PAD GROUNDING,,0270,,14.58,10.935,10.935
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],12.2,9.15,9.15,4.18,2.41,10,,,,,,CANNULA PEDI,,0270,,5.82,4.365,4.365
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,CANNULA NASAL OXYGEN (ADULT),,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,15.71,5.43,37.5,,,,,,CANNULA BLUNT PLASTIC,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85045,Lab analysis to measure red blood count (automated test) [HCPCS 85045],100.4,75.3,75.3,42.06,6.62,61.04,,,,,,CANOPY OXYGEN TENT,,0270,,27.26,20.445,20.445
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85060,Lab analysis to interpret a blood smear by physician with written report [HCPCS 85060],78.4,58.8,58.8,32.82,24.12,32.82,,,,,,CATHETER ACCUTRACE IUPC,,0272,,42.49,31.8675,31.8675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,80.39,8.55,182.7,,,,,,CATH SECURE HOLDER,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,29.13,3.6,69.6,,,,,,CATHETER COUDE 14FR 5cc,,0272,,40.08,30.06,30.06
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,18.48,3.56,42,,,,,,CATHETER COUDE 16FR. 5CC,,0272,,24.72,18.54,18.54
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,30.05,2.7,54.33,,,,,,CATHETER COUDE 18 FR.5cc,,0272,,40.08,30.06,30.06
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,29.13,6.03,69.6,,,,,,CATHETER COUDE 20FR.,,0272,,24.85,18.6375,18.6375
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86021,Lab analysis to identify antibodies to white blood cells [HCPCS 86021],1088.3,816.23,816.23,27.1,27.1,661.69,,,,,,CATHETER THORACIC 12 FR.,,0272,,20.12,15.09,15.09
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,65.16,12.29,258.33,,,,,,CATHETER THORACIC 16 FR.,,0272,,19.21,14.4075,14.4075
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86039,Lab analysis to screen for autoimmune disorders by titer [HCPCS 86039],91.6,68.7,68.7,38.37,18.5,73.28,,,,,,CATHETER THORACIC 20 FR.,,0272,,19.21,14.4075,14.4075
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86060,Lab analysis to identify strep throat antibody [HCPCS 86060],48.6,36.45,36.45,20.33,7.42,20.33,,,,,,CATHETER THORACIC 24 F,,0272,,19.2,14.4,14.4
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,31.9,5.26,76.2,,,,,,CATHETER THORACIC 28FR,,0272,,15.23,11.4225,11.4225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86141,Lab analysis to measure the amount of C-reactive protein in serum by high sensitivity assay to identify infection or inflammation [HCPCS 86141],155.5,116.63,116.63,65.16,22.11,65.16,,,,,,CATHETER THORACIC 36 FR.,,0272,,19.21,14.4075,14.4075
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,60.98,12.2,112.96,,,,,,CATHETER THORACIC 40 FR.,,0272,,16.59,12.4425,12.4425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86200,Lab analysis to identify antibodies for rheumatoid arthritis assessment [HCPCS 86200],202.9,152.18,152.18,85.01,85.01,85.01,,,,,,CATHETER TROCAR 20FR,,0272,,43.75,32.8125,32.8125
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86225,Lab analysis to identify antibodies to native or double stranded DNA [HCPCS 86225],141.2,105.9,105.9,62.13,62.13,112.96,,,,,,CATHETER TROCAR 28 FR.,,0272,,37.22,27.915,27.915
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,94.73,18.22,199.4,,,,,,CATHETER TROCAR 32 FR.,,0272,,37.22,27.915,27.915
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,97.94,12.25,187.04,,,,,,CATHETER URETHRAL 12FR,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86256,Lab analysis to identify antibody to noninfectious agents [HCPCS 86256],115.9,86.93,86.93,48.53,48.53,48.53,,,,,,CATHETER URETHRAL 14 F(RED RUBBER),,0272,,11.53,8.6475,8.6475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86301,"Lab analysis to idenitfy tumor antigens by immunoassay (quantitative, CA 19-9) [HCPCS 86301]",134.5,100.88,100.88,56.36,56.36,56.36,,,,,,CATHETER (SIL) 10FR-3CC,,0272,,11.82,8.865,8.865
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86304,"Lab analysis to identify tumor antigens by immunoassay (quantitative, CA 125) [HCPCS 86304]",311,233.25,233.25,130.28,130.28,207.71,,,,,,CATHETER 12FR-5CC,,0272,,11.4,8.55,8.55
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86335,Lab analysis by immunologic analysis technique on body fluid (other fluids with concentration) [HCPCS 86335],155.5,116.63,116.63,65.16,29.83,102.82,,,,,,CATHETER 14FR-5CC (SILICONE),,0272,,11.4,8.55,8.55
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,50.82,14.79,121.3,,,,,,CATHETER 16FR-5CC,,0272,,7.49,5.6175,5.6175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,78.1,5.76,186.4,,,,,,CATHETER COUDE 18FR-5CC,,0272,,27.59,20.6925,20.6925
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],421.2,315.9,315.9,176.48,176.48,278.51,,,,,,CATHETER 22FR-5CC,,0272,,11.75,8.8125,8.8125
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,25.87,4.34,61.8,,,,,,CATHETER 26FR-5CC,,0272,,11.72,8.79,8.79
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86617,Lab analysis to identify antibodies to Borrelia burgdorferi (Lyme disease bacteria) with confirmation test [HCPCS 86617],147.8,110.85,110.85,61.91,25.68,61.91,,,,,,CATHETER 28FR-5CC,,0272,,21.83,16.3725,16.3725
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,50.82,11.52,121.3,,,,,,CATHETER 30FR-30CC,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86705,Lab analysis to identify Hepatitis B core antibodies (IgM) [HCPCS 86705],130.1,97.58,97.58,54.52,54.52,54.52,,,,,,CATHETER 30FR-5CC,,0272,,17.48,13.11,13.11
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86706,Lab analysis to identify Hepatitis B surface antibodies [HCPCS 86706],113.7,85.28,85.28,47.61,42.06,47.61,,,,,,CATHETER 8FR-3CC,,0272,,11.82,8.865,8.865
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,39.29,16.62,74.01,,,,,,CATHETER THORACIC 32 FR,,0272,,15.23,11.4225,11.4225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,93.32,11.99,222.7,,,,,,CATHETER URETHRAL ADAPTER 4-6FR,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,32.82,6.74,92.02,,,,,,DETECTOR CO2 MINI STAT02,,0272,,43.81,32.8575,32.8575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86870,Lab blood analysis to identify antibodies to red blood cells [HCPCS 86870],201.9,151.43,151.43,0,9.61,182.51,,,,,,CATHETER 20FR. 5CC,,0272,,16.21,12.1575,12.1575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86880,"Lab blood analysis to identify the coating of red blood cells by antibody (Coombs test) (direct, each serum) [HCPCS 86880]",160,120,120,31.42,5.48,31.42,,,,,,CATHETER 20FR-30CC,,0272,,13.51,10.1325,10.1325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,25.87,2.99,62.24,,,,,,CATHETER 22FR-30CC,,0272,,13.76,10.32,10.32
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,20.33,2.99,48.11,,,,,,CATHETER 28FR-30CC,,0272,,16.46,12.345,12.345
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,51.75,11.93,144.95,,,,,,CATHETER 16 FR 30 CC,,0272,,9.96,7.47,7.47
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,59.14,9.2,112.32,,,,,,CATHETER 18 FR 30 CC,,0272,,25.84,19.38,19.38
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],54.4,40.8,40.8,22.79,9.6,22.79,,,,,,CAUTERY CORDLESS HI-TEMP,,0272,,21.18,15.885,15.885
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87046,Lab analysis of stool culture to identify bacteria and additional pathogens [HCPCS 87046],54.4,40.8,40.8,0,7.93,15.66,,,,,,CIRCUIT VENTILATOR ADT,,0272,,11.79,8.8425,8.8425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,41.58,7.24,496.86,,,,,,CLAMP OSTOMY,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,61.91,9.38,86.39,,,,,,CLIP LIGATING LRG MCL20,,0272,,103.73,77.7975,77.7975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.06,6.79,100.4,,,,,,CLIP LIGATING MED/LRG MCM20,,0272,,102.59,76.9425,76.9425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,41.58,5.57,65.1,,,,,,COLLAR CERV STIFNECK ADJUST ADULT,,0270,,13.92,10.44,10.44
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,45.28,2.84,108.1,,,,,,COLLAR CERVICAL PEDI,,0270,,21.35,16.0125,16.0125
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,10.38,6.8,52.43,,,,,,COLLAR CERVICAL-LG,,0270,,13.94,10.455,10.455
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87106,Lab analysis of fungal culture to identify yeast [HCPCS 87106],152.2,114.15,114.15,29.64,8.67,29.64,,,,,,COLLAR CERVICAL-MD,,0270,,14.83,11.1225,11.1225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],56.8,42.6,42.6,23.8,8.9,23.8,,,,,,COLLAR CERVICAL-SM,,0270,,14.05,10.5375,10.5375
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.07,7.27,172,,,,,,COLLAR PHILADELPHIA 3 1/4,,0270,,35.26,26.445,26.445
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,21.74,4.29,39.3,,,,,,COLLAR PHILADELPHIA 4 1/4,,0270,,33.89,25.4175,25.4175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],56.8,42.6,42.6,23.8,12.41,29.8,,,,,,"COLLECTOR URINE, PEDI",,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87329,Lab analysis by immunoassay (ELISA) to identify giardia (intestinal parasite) [HCPCS 87329],186.4,139.8,139.8,78.1,19.86,78.1,,,,,,CONNECTOR ( 5 IN 1 ) 1,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87339,Lab analysis by immunoassay (ELISA) to identify helicobacter pylori (GI tract bacteria) [HCPCS 87339],217.3,162.98,162.98,16,13,16,,,,,,TUBING CONNECTOR 001811,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87340,Lab analysis by immunoassay (ELISA) to identify Hepatitis B surface antigen [HCPCS 87340],105.9,79.43,79.43,44.35,10.5,44.35,,,,,,CONNECTOR Y 6 IN 1,,0270,,5.91,4.4325,4.4325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,65.16,8.17,155.5,,,,,,CONTROL A FLO (I/V),,0272,,12.59,9.4425,9.4425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,44,37.79,110.3,,,,,,CRUTCHES ADULT TALL HEIGHT,,0270,,25.08,18.81,18.81
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],211.7,158.78,158.78,22.79,11.89,22.79,,,,,,CRUTCHES CHILD,,0270,,29.11,21.8325,21.8325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,32.82,14.12,74.6,,,,,,CRUTCHES ADULT MEDIUM HEIGHT,,0270,,25.21,18.9075,18.9075
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",342.7,257.03,257.03,22.84,11.91,22.84,,,,,,CRUTCHES YOUTH,,0270,,24.44,18.33,18.33
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,35.09,29.48,155.5,,,,,,CUFF BLD PRESS-DISP LARGE ADULT (2 TUBE),,0270,,20.83,15.6225,15.6225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],282.3,211.73,211.73,118.27,31.31,118.27,,,,,,CUFF BLD PRESS-DISP SMALL ADULT (2 TUBE),,0270,,20.83,15.6225,15.6225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87497,Lab analysis by nucleic acid (DNA or RNA) to measure the amount of cytomegalovirus [HCPCS 87497],466.5,349.88,349.88,195.45,195.45,311.58,,,,,,CUFF BLD PRESS-DISP STANDARD ADLT (2TUBE,,0270,,20.83,15.6225,15.6225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87522,Lab analysis to measure the amount of Hepatitis C virus [HCPCS 87522],325.3,243.98,243.98,143.13,143.13,322.55,,,,,,CUFF BLOOD PRESS SZ-5,,0270,,14.18,10.635,10.635
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,81.42,29.48,155.5,,,,,,CUFF BLOOD PRESS SZ-4,,0270,,14.24,10.68,10.68
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,69.3,45.82,378.9,,,,,,CURETTE VACCUM 8MM,,0270,,11.97,8.9775,8.9775
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,45.28,29.48,105,,,,,,CURETTE VACUUM 7MM,,0272,,13.07,9.8025,9.8025
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87798,Lab analysis by nucleic acid (DNA or RNA) to identify organism by amplified probe technique [HCPCS 87798],638.4,478.8,478.8,267.52,267.52,426.39,,,,,,CURETTE VACUUM 9MM,,0272,,11.97,8.9775,8.9775
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,184.17,40.24,406.9,,,,,,CURETTE VACUUM 12MM,,0272,,10.54,7.905,7.905
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,88108,Lab examination of specimen by the conentration technique to diagnose disease [HCPCS 88108],33.1,24.83,24.83,13.86,13.86,38.85,,,,,,ENDO STAPLER ARTICULATING 45MM,,0272,,326.06,244.545,244.545
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,13.86,13.86,24.19,,,,,,CUTTER LINEAR 55MM TLC,,0272,,164.17,123.1275,123.1275
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,69.23,20.12,77.89,,,,,,CUTTER LINER RELOAD TRT75 DR. A,,0272,,140.38,105.285,105.285
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,89055,Lab analysis to measure the amount of white blood cells in stool specimen [HCPCS 89055],65.1,48.83,48.83,27.28,3.59,27.28,,,,,,CUTTER RELOAD REFIL 75MM TCR75,,0272,,137.68,103.26,103.26
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,92950,Heart and lungs restart (attempt) [HCPCS 92950],695.8,521.85,521.85,71.63,71.63,200.7,,,,,,DERMA GRAN B WOUND HYDROPHILIC 3oz.,,0270,,28.48,21.36,21.36
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,51.3,6.15,4344.87,,,,,,DERMA GRAN OINTMENT,,0270,,19.69,14.7675,14.7675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],469.7,352.28,352.28,196.81,196.81,380.21,,,,,,DERMA GRAN WOUND CLEANSER,,0270,,10.11,7.5825,7.5825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",296.7,222.53,222.53,129.31,24.86,180.39,,,,,,DETACHOL,,0270,,5.51,4.1325,4.1325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,196.37,39.27,311.42,,,,,,DIAPERS SZ 1,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],713.4,535.05,535.05,307.94,307.94,471.72,,,,,,DISH LAP LRG - LD112,,0272,,"2,047.5",1535.625,1535.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93925,Leg ultrasound of arteries and arterial grafts of both legs (complete study) [HCPCS 93925],1018.8,764.1,764.1,426.89,350.85,673.66,,,,,,DISH LAP MED LD111,,0272,,"2,047.5",1535.625,1535.625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93926,Arteries and arterial grafts ultrasound of one leg (limited study) [HCPCS 93926],713.4,535.05,535.05,298.94,166.13,606.39,,,,,,DRAIN PENROSE 1/2 X 12,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",1427.8,1070.85,1070.85,598.31,350.85,944.09,,,,,,DRAIN PENROSE 1/4 X 12,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,298.94,166.13,1092.27,,,,,,DRAIN PENROSE 3/4 X 12,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93976,"Abdominal, pelvic, and/or scrotal arterial inflow and venous outflow ultrasound (limited study) [HCPCS 93976]",649.5,487.13,487.13,272.14,272.14,272.14,,,,,,DRAIN PENROSE 3/4 X 18,,0272,,42.36,31.77,31.77
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,94002,Hospital inpatient or observation patient ventilator management care (initial day) [HCPCS 94002],758.6,568.95,568.95,317.86,317.86,317.86,,,,,,DRAIN JACKSON PRATT 7,,0272,,13.04,9.78,9.78
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,94060,Amount and speed of breathed air measurement and graphic recording before and after medication administration [HCPCS 94060],308.7,231.53,231.53,20,20,362.32,,,,,,DRAIN JACKSON PRATT 10,,0272,,13.04,9.78,9.78
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,35.11,16.49,98.36,,,,,,DRAPE FENESTRATED,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,94660,CPAP (continuous positive airway pressure) mask or breathing tube initiation and management for night time respiratory muscle rest [HCPCS 94660],548,411,411,229.64,229.64,312.36,,,,,,Steri-Drape Large Towel Drape With Surgical Adhesive,,0270,,30.44,22.83,22.83
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,35.11,19.15,448.97,,,,,,DRAPE 1/2 SHEET,,0270,,43.65,32.7375,32.7375
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,187.13,28.6,1161.38,,,,,,DRAPE EXTREMITY,,0270,,217.15,162.8625,162.8625
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,32.34,16.26,2475.42,,,,,,DRAPE LAP CHOLE,,0270,,212.16,159.12,159.12
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,187.13,68.61,524.17,,,,,,DRAPE MAYO STAND,,0270,,49.41,37.0575,37.0575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,32.34,20.72,3197.1,,,,,,"DRAPE STERI 15 APERTURE SM M1020""",,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,34.19,34.19,143.78,,,,,,DRESSING ADAPTIC 3X8 (2013),,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96368,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (concurrent with another infusion) [HCPCS 96368]",92.7,69.53,69.53,38.81,38.81,108.8,,,,,,DRESSING BURN ACTICOAT 4 X 4,,0272,,22.34,16.755,16.755
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,69.04,4.51,1156.79,,,,,,DRESSING TEGADERM FOAM SQ. 3 1/2 X 3 1/2,,0272,,7.86,5.895,5.895
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,83.64,29.4,2785.69,,,,,,DRESSING HYDROFERA BLUE 4 X 4,,0272,,18.38,13.785,13.785
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,16.63,12.56,48.28,,,,,,BANDAGE KERLIX 3,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,15.71,10.24,44.01,,,,,,MESALT 3/4 X 39 DRESSING,,0272,,6.76,5.07,5.07
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,20.33,13.42,41.31,,,,,,DRESSING TRANSPARENT TEGADERM 6X8,,0272,,5.46,4.095,4.095
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97014,Electrical stimulation application to 1 or more areas (unattended by physical therapist) [HCPCS 97014],62.9,47.18,47.18,0,38.24,38.24,,,,,,DRESSING WOUND AQUACEL ROPE,,0272,,15.14,11.355,11.355
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97018,Hot wax bath application to 1 or more areas [HCPCS 97018],72.8,54.6,54.6,29.04,29.04,29.04,,,,,,DRESSING(do not use) 4 X 5 1/2 LG OPSITE,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,47.12,40.84,136.8,,,,,,DRESSING ADAPTIC 5X9,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,51.3,40.84,143.78,,,,,,DRESSING AQUACELL AG W/SILVER IMPREG 6X6,,0272,,48.38,36.285,36.285
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],101.5,76.13,76.13,42.5,37.78,80.08,,,,,,DRESSING COBAN 4,,0270,,5.73,4.2975,4.2975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,35.11,23.51,98.36,,,,,,DRESSING CURASORB CALCIUM ALGINATE ROPE,,0272,,11.11,8.3325,8.3325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,152.94,140.59,428.4,,,,,,BANDAGE KERLIX 4,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,152.94,140.59,241.75,,,,,,DRESSING(do not use) OPSITE 2 3/8 X 2 3/4,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],247,185.25,185.25,103.49,103.49,144.41,,,,,,DRESSING POLYMEM 2X2,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,55,40.84,154.11,,,,,,DRESSING POLYMEM 3X3,,0272,,14.19,10.6425,10.6425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97597,Tissue removal from wounds per session (first 20 sq cm or less) [HCPCS 97597],709,531.75,531.75,297.09,85.58,468.8,,,,,,DRESSING POLYMEM 5X5,,0272,,25.31,18.9825,18.9825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,13.86,10.32,28.14,,,,,,DRESSING SURGI/ABD PAD-5X9,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99195,Whole blood removal by needle to correct blood level imbalance [HCPCS 99195],175.4,131.55,131.55,73.48,73.48,115.98,,,,,,DRESSING SURGIPAD-7 1/2 x 8,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,237.32,35.11,337.46,,,,,,DRESSING TEGADERM 4,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,243.62,70.45,319.43,,,,,,DRESSING TEGADERM 4 X 4 3/4,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,2.2,2.2,117.5,,,,,,DRESSING TEGADERM-ABS,,0272,,24.49,18.3675,18.3675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,102.56,39.1,434.06,,,,,,DRESSING TELFA 2X3,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,161.26,61.48,2109.82,,,,,,DRESSING TELFA 3X4,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,238.88,50,3116.59,,,,,,DRESSING XEROFORM 5X9,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,392.26,62.92,1098.7,,,,,,DRESSING TEGADERM 2 3/8 X 2 3/4,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,C9803,Hopd covid-19 spec collect [HCPCS C9803],64.7,48.53,48.53,0,37.54,37.54,,,,,,DRESSING 3 1/2 X 4 TEGA,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],3736.08,2802.06,2802.06,1246.96,1246.96,1246.96,,,,,,DRESSING ADAPTIC 3 X 3,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,62.22,2.42,250.2,,,,,,DRESSING DUODERM 4X4,,0272,,7.82,5.865,5.865
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,G0283,Elec stim other than wound [HCPCS G0283],62.9,47.18,47.18,26.36,26.36,35.85,,,,,,DRESSING TELFA 8x3,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,G0328,Fecal blood scrn immunoassay [HCPCS G0328],48.8,36.6,36.6,20.42,20.42,48.31,,,,,,DRESSING XEROFORM 2 X 2,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,10.16,5.83,3301.98,,,,,,DETECTOR C02 EASY CAP,,0270,,22.18,16.635,16.635
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,10.16,7.4,19.63,,,,,,ELECTRODE SPIRAL FETAL,,0270,,14.1,10.575,10.575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,5.74,3.22,2266.54,,,,,,ELECTRODE ADULT PACING (PHYSIO),,0270,,45.05,33.7875,33.7875
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0295,Ampicillin sulbactam 1.5 gm [HCPCS J0295],21.52,16.14,16.14,9.47,3.38,9.47,,,,,,ENDO-POUCH,,0272,,82.29,61.7175,61.7175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0330,Succinycholine chloride inj [HCPCS J0330],3.95,2.96,2.96,1.74,1.74,3.04,,,,,,RELOAD ENDOCUTTER 45MM 6R45M,,0272,,232.34,174.255,174.255
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0360,Hydralazine hcl injection [HCPCS J0360],36,27,27,15.84,6.88,317.84,,,,,,ENDOLOOP EZ10G,,0272,,67.75,50.8125,50.8125
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,5.5,5.5,14.67,,,,,,ENDOTRACHEAL TUBE HOLD,,0272,,12.6,9.45,9.45
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2.75,0.68,2868.2,,,,,,ENEMA (bag) BUCKET,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0744,Ciprofloxacin iv [HCPCS J0744],10,7.5,7.5,4.4,0.99,4.8,,,,,,ENEMA MINER OIL LUBRICANT LAXATIVE DOSE,,0272,,7.61,5.7075,5.7075
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,24.42,13.53,65.14,,,,,,FLOW SENSOR RESP CARE,,0270,,7.39,5.5425,5.5425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J0881,"Darbepoetin alfa, non-esrd [HCPCS J0881]",18.58,13.94,13.94,8.17,8.17,8.17,,,,,,FOAM APPL LG 3.0MC,,0270,,5.49,4.1175,4.1175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,2.75,0.11,332.88,,,,,,FOAM APPL SM 1.0MC,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,11,2.1,2819.66,,,,,,FOOT PRINTER,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J1265,Dopamine injection [HCPCS J1265],3.89,2.92,2.92,1.71,1.71,4.56,,,,,,FORCEP BIOPSY(do not use),,0272,,25.96,19.47,19.47
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J1610,Glucagon hydrochloride/1 mg [HCPCS J1610],409.2,306.9,306.9,180.05,180.05,273.3,,,,,,FORCEP HOT BIOPSY( do not use),,0272,,53.07,39.8025,39.8025
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J1650,Inj enoxaparin sodium [HCPCS J1650],14.44,10.83,10.83,0.47,0.47,8.78,,,,,,FORCEP OPTIBITE,,0272,,42.13,31.5975,31.5975
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,5.5,5.5,1162.88,,,,,,TUBING & CONNECTER URINARY EXTENSION,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J1956,Levofloxacin injection [HCPCS J1956],12.5,9.38,9.38,5.5,5.5,16.47,,,,,,GAUZE PLAIN 1,,0272,,9.23,6.9225,6.9225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,1.1,0.73,808.23,,,,,,GAUZE PLAIN 2,,0272,,8.7,6.525,6.525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,11,7.08,29.34,,,,,,GAUZE IODOFORM 1,,0272,,6.64,4.98,4.98
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,11,7.8,30.4,,,,,,GAUZE IODOFORM 1/2,,0272,,8.3,6.225,6.225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,5.5,5.5,14.67,,,,,,GAUZE IODOFORM 1/4,,0272,,7.87,5.9025,5.9025
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,11,3.15,30.39,,,,,,GAUZE IODOFORM 2,,0272,,10.21,7.6575,7.6575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,11,11,29.34,,,,,,GAUZE PLAIN 1/4,,0272,,5.96,4.47,4.47
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2354,"Octreotide inj, non-depot [HCPCS J2354]",7.46,5.6,5.6,0,4.53,4.53,,,,,,GAUZE VASELINE 6X36,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,5.5,0.95,3583.7,,,,,,GAUZE VASELNE 1X36,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,3.67,1.72,16.28,,,,,,GAUZE PLAIN 1/2,,0272,,7.96,5.97,5.97
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,11,2.81,811.33,,,,,,GEL MULTIDEX 1/4 oz.,,0272,,11.02,8.265,8.265
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.55,0.55,29.34,,,,,,GEL MULTIDEX 3 OZ,,0272,,41.9,31.425,31.425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,12.8,5.49,347.63,,,,,,GELFOAM (SURGIFOAM) SPONGE SIZE 100,,0272,,88.32,66.24,66.24
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,2.81,1.29,348.28,,,,,,GLOVE MICROPTIC,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J3360,Diazepam injection [HCPCS J3360],36.92,27.69,27.69,16.25,16.25,16.25,,,,,,GLOVE NONSTERILE EXAM X-SM,,0270,,14.21,10.6575,10.6575
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,5.5,5.5,19.14,,,,,,GLOVES SZ 7 N/LATEX FR,,0270,,6.3,4.725,4.725
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],20,15,15,8.8,0.84,14.68,,,,,,GLOVES SZ 8.5 STERILE LATEX FREE (green box),,0270,,5.02,3.765,3.765
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,8.8,1.66,23.47,,,,,,GLOVES LG-SINGLE LATEX FREE,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,1.76,1.76,23.48,,,,,,GLOVES MED-SINGLE,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,15.4,0.02,4433.9,,,,,,GLOVES STER-LATEX FREE SZ. 6,,0270,,125.13,93.8475,93.8475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,0,2.4,4.25,,,,,,GLOVES STRL SZ 8 N/LATEX (green box),,0270,,5.39,4.0425,4.0425
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J7620,Albuterol ipratrop non-comp [HCPCS J7620],5.47,4.1,4.1,2.41,2.41,4.65,,,,,,GOWN STERILE,,0270,,13.29,9.9675,9.9675
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,213.71,167.53,728.8,,,,,,GRADUATE MEASURING DEV,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,U0004,"2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r [HCPCS U0004]",89.3,66.98,66.98,39.29,39.29,43.47,,,,,,HIBICLENS 4 OZ.,,0272,,14.28,10.71,10.71
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,97.06,59.92,194.57,,,,,,HISTOFREEZER,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,237.32,35.11,337.46,,,,,,HOLDER NEEDLE,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],282.5,211.88,211.88,120.41,120.41,120.41,,,,,,AQUAPAK 301 HUMIDIFIER WATER 003-01 RESP,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],310.8,233.1,233.1,130.46,130.46,326.4,,,,,,HYDROGEN PEROXIDE 4 OZ,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],103.1,77.33,77.33,35.33,35.33,37.53,,,,,,INLINE BURETTE,,0272,,14.43,10.8225,10.8225
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],189.7,142.28,142.28,0,69.53,69.53,,,,,,JAWLOCK BITE (MEDLINE),,0272,,5.14,3.855,3.855
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],162.8,122.1,122.1,64.49,64.49,171,,,,,,JELCO I.V. CATHETER 22,,0272,,5.04,3.78,3.78
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],326.6,244.95,244.95,126.93,126.93,126.93,,,,,,JELCO I.V. CATHETER 24,,0272,,5.13,3.8475,3.8475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",314,235.5,235.5,69.82,55.67,329.7,,,,,,JELCO I.V. CATHETER 18,,0272,,5.11,3.8325,3.8325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",310.8,233.1,233.1,95.48,95.48,95.48,,,,,,JELCO I.V. CATHETER 16,,0272,,5.16,3.87,3.87
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,0,3.97,330,,,,,,JELCO I.V. CATHETER 20,,0272,,5.11,3.8325,3.8325
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,1.64,1.64,80.91,,,,,,JELCO I.V. CATHETER 14,,0272,,5.13,3.8475,3.8475
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,1.93,1.93,464.4,,,,,,K-Y JELLY BOTTLE,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,830,Anesthesia provided during lower abdominal hernia repair [HCPCS 00830],139,104.25,104.25,1.95,1.95,28.42,,,,,,KIT BLOOD GAS,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,179.75,51.74,302.2,,,,,,KIT FEMALE CATHETER,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,195.09,192.01,343.2,,,,,,KIT IV PREP,,0272,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,246.4,168.37,416.16,,,,,,KIT MIDSTREAM W/TOWLETTES,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,49505,Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505],1904.1,1428.08,1428.08,503.48,503.48,841.81,,,,,,KIT RAPE EVIDENCE,,0272,,44.51,33.3825,33.3825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,56405,Female genitals abscess incision and drainage [HCPCS 56405],596.5,447.38,447.38,121.4,121.4,121.4,,,,,,KNEE CAP SUPPORT LARGE,,0270,,24.54,18.405,18.405
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,351.42,214.38,2255.8,,,,,,KNEE CAP SUPPORT MEDIUM,,0270,,24.54,18.405,18.405
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,69.82,52.38,170.1,,,,,,KNEE CAP SUPPORT X-LRG,,0270,,24.54,18.405,18.405
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,94.91,52.53,206.9,,,,,,KNEE CAP-SUPPORT SM,,0270,,24.54,18.405,18.405
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,129.79,81.71,178.67,,,,,,"KNEE IMMOBILIZER,SMALL",,0270,,40.44,30.33,30.33
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],371.6,278.7,278.7,169.74,122.95,194.97,,,,,,"KNEE IMMOBILIZER,LARGE",,0270,,41.67,31.2525,31.2525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,97.06,59.92,194.57,,,,,,KNEE IMMOBILIZER-XLG,,0270,,41.68,31.26,31.26
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,131.34,95.05,222.03,,,,,,KNEE IMMOBILIZER-XXLG,,0270,,41.67,31.2525,31.2525
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,193.71,120.14,248.05,,,,,,"KNEE IMMOBILIZER,MEDIUM",,0270,,41.71,31.2825,31.2825
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.53,22.37,41.75,,,,,,KNEE SUPPORT-SM,,0270,,24.78,18.585,18.585
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,69.53,39.55,134.08,,,,,,COVER LIGHT HANDLE,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,KIT TUBE GASTRIC LAVAGE 34FR.,,0272,,80.26,60.195,60.195
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,69.53,45.48,91.29,,,,,,LENS DELIVER SET (MORT,,0272,,22.52,16.89,16.89
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],257,192.75,192.75,99.96,99.96,130.9,,,,,,LENS MEDI-FLOW (MORTAN),,0272,,70.16,52.62,52.62
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,126.93,114.76,176.55,,,,,,CANNULA LEVER LOCK,,,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.82,59.99,274.04,,,,,,LIGA CLIP LRG. ER420,,0272,,150.26,112.695,112.695
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,101.89,33.41,326.4,,,,,,LOPEZ VALVE,,0272,,5.25,3.9375,3.9375
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],593.2,444.9,444.9,123.23,123.23,125.38,,,,,,MALE ADAPTOR PLUG INTR,,0270,,5,3.75,3.75
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,41.76,41.76,46.23,,,,,,MASK NEONATE,,0270,,6.69,5.0175,5.0175
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",333,249.75,249.75,69.22,69.22,77.17,,,,,,MASK LMA SIZE 1,,0272,,13.48,10.11,10.11
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,78.4,4.51,1156.79,,,,,,MASK LMA SIZE 1.5,,0272,,13.48,10.11,10.11
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,86.35,70.45,319.43,,,,,,MASK LMA SIZE 2,,0272,,13.48,10.11,10.11
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Institutional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],31.47,23.6,23.6,15.1,15.1,23.42,,,,,,MASK LMA SIZE 3,,0272,,13.62,10.215,10.215
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.3,5.3,61.31,,,,,,MASK LMA SIZE 4,,0272,,13.62,10.215,10.215
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,14,12.82,82,,,,,,MASK MA SIZE 2 1/2,,0272,,13.48,10.11,10.11
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,MASK AEROSOL ADULT,,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,MASK AEROSOL (PEDI),,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,89.65,45.56,141.93,,,,,,MASK FACE TENT,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,131.45,91.42,145.6,,,,,,MASK OXYGEN-PEDIATRIC,,0270,,14.65,10.9875,10.9875
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,MASK OXYGEN/SIMPLE (ADULT),,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,MASK PARTICULATE N95 LG(1870+),,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,MASK PARTICULATE N95 MED(1860),,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.2,1.1,17.76,,,,,,MASK TRACH/ADULT,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.77,2.44,580.94,,,,,,MASK VENTURI ADULT,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,146.38,20.71,250.4,,,,,,"MASK NONREBREATHER,1203",,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,164.95,28.74,271.3,,,,,,MASTISOL,,0272,,5.94,4.455,4.455
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,131.52,94.25,191.25,,,,,,MESH PROLENE KEYHOLE (PMSK),,0278,,87.06,65.295,65.295
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,131.52,57.76,225,,,,,,MINIVOLUMNE EXTENSION SET,,0270,,5.64,4.23,4.23
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,136.8,94.25,214.2,,,,,,REUSEABLE MITTS FINGERCONTROL,,0270,,32.6,24.45,24.45
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1513.62,180.22,3324.06,,,,,,MOUTHPIECE ENDOSCOPE,,0270,,146.66,109.995,109.995
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,397.57,137.3,529.3,,,,,,MULTIDEX POWDER 12GM,,0270,,24.61,18.4575,18.4575
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,"MULTIDEX POWDER, 25GM",,0272,,26.66,19.995,19.995
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,94.54,43.35,182.52,,,,,,"NEBULIZER,JET (MISTY)",,0270,,61.67,46.2525,46.2525
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,46.33,2.66,76.2,,,,,,"NEBULIZER,UPDRAFT/SVN",,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,49.61,6.2,81.6,,,,,,NEEDLE HUBER 20G 1 1/2,,0272,,8.15,6.1125,6.1125
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,81511,"Lab analysis of four analytes (afp, ue3, hcg [any form], dia) from maternal serum to identify the risk of fetal birth defects [HCPCS 81511]",657.1,492.83,492.83,399.52,124.73,771.24,,,,,,NEEDLE HUBER 22G 1,,0272,,9.72,7.29,7.29
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,15.47,2.31,20.91,,,,,,NEEDLE HUBER 22G 3/4(discopervendor),,0272,,10.93,8.1975,8.1975
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,58.37,5.44,96,,,,,,NEEDLE INJECTION SURESHOT,,0272,,79.46,59.595,59.595
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,82378,Lab analysis to measure the carcinoembryonic antigen (cea) protein level [HCPCS 82378],202.9,152.18,152.18,123.36,85.01,123.36,,,,,,NEEDLE ASPIRATION BONE MARROW,,0272,,28.99,21.7425,21.7425
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,65.1,5.81,65.1,,,,,,NEEDLE BIOPSY DISPOSA,,0272,,37.86,28.395,28.395
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,56.73,4.35,81.23,,,,,,NEEDLE FILTER,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,67.72,8.16,104.31,,,,,,NEEDLE SPINAL 20G 1 1/4,,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,64.39,5,105.9,,,,,,NEEDLE SPINAL 22 5,,0272,,15.07,11.3025,11.3025
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,165.04,32.98,268.8,,,,,,NEEDLE SPINAL 22G 1/2,,0272,,5.65,4.2375,4.2375
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],144.5,108.38,108.38,87.86,18.12,87.86,,,,,,NEEDLE SPINAL 25 G 4 3/4,,0272,,9.38,7.035,7.035
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,191.76,18.45,315.4,,,,,,NEEDLE SPINAL 25G 3 1/2,,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,79.1,7.58,134.6,,,,,,NEEDLE SPINOCAN,,0272,,37.21,27.9075,27.9075
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,82.51,14.11,134.34,,,,,,NEEDLE VERESS UV120,,0272,,39.84,29.88,29.88
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,94.54,14.41,153.94,,,,,,NEEDLE SPINAL 22G 3 1/2,,0272,,9.36,7.02,7.02
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,141.2,9.87,141.2,,,,,,NITRO LIPID SET,,0272,,14.64,10.98,10.98
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.63,6,88.2,,,,,,SALINE 1000ML NORMAL-SOD CHLO,,0270,,5.48,4.11,4.11
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,112.18,8.55,182.7,,,,,,SALINE 250ml NORMAL -SOD CHLO,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,37.57,4.34,61.8,,,,,,OB VACUUM DEL SET,,0272,,41.18,30.885,30.885
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,86695,"Lab analysis to identify antibodies to Herpes simplex virus, type 1 [HCPCS 86695]",194.1,145.58,145.58,58.37,13.41,58.37,,,,,,OXISENSOR PEDI-ASP-3P,,0272,,24.67,18.5025,18.5025
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,86696,"Lab analysis to identify antibodies to Herpes simplex virus, type 2 [HCPCS 86696]",413.5,310.13,310.13,88.19,19.67,254.75,,,,,,OXISENSOR ADT-LONG,,0270,,41.51,31.1325,31.1325
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,73.75,11.52,121.3,,,,,,SENSOR O2 NELCOR DISP REG/ADULT,,0272,,24.66,18.495,18.495
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,58.7,6.79,100.4,,,,,,OXYGEN NEONATE,,0270,,32.38,24.285,24.285
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,108.1,2.84,108.1,,,,,,PACK C-SECTION(do not use),,0272,,51.16,38.37,38.37
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,14.49,6.8,52.43,,,,,,PACK BASIC,,0272,,30.86,23.145,23.145
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,100.57,7.27,172,,,,,,PACK GYNECOLOGY,,0272,,14.57,10.9275,10.9275
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87254,Lab analysis of isolated viruses by centrifuge enhanced method [HCPCS 87254],419,314.25,314.25,254.75,19.88,254.75,,,,,,PACK ICE/DISP,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,94.54,8.17,155.5,,,,,,PACK LAP CHOLECYSTECTOMY,,0272,,54.52,40.89,40.89
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,155.5,29.48,155.5,,,,,,PACK LAPARASCOPE,,0272,,20.81,15.6075,15.6075
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,155.5,29.48,155.5,,,,,,PACK LAPARATOMY,,0272,,32.21,24.1575,24.1575
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,100.56,45.82,378.9,,,,,,PACK EXTREMITY III,,0272,,37.17,27.8775,27.8775
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,63.84,29.48,105,,,,,,PACK OB( do not use),,0272,,31.16,23.37,23.37
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,122.5,6.15,4344.87,,,,,,PAD EYE(DO NOT USE),,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,274.03,39.27,311.42,,,,,,LEG ATTACHMENT PAD,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,271.53,28.6,1161.38,,,,,,PASTE KARAYA,,0270,,13.74,10.305,10.305
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,97.1,16.26,2475.42,,,,,,PEAK FLOW METER,,0270,,37.78,28.335,28.335
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,446.6,68.61,524.17,,,,,,STYLETTE PEDI 6.0,,0272,,8.5,6.375,6.375
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,78.4,4.51,1156.79,,,,,,HANDSWITCH PENCILS PREMIUM CAUTERY,,0270,,13.32,9.99,9.99
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,121.36,29.4,2785.69,,,,,,PLUG CATHETER,,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,24.14,12.56,48.28,,,,,,PRIMARY CONT-FLO I/V,,0272,,9.47,7.1025,7.1025
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,10.32,10.32,28.14,,,,,,PROLENE 3D PATCH,,0278,,401.3,300.975,300.975
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,384.9,61.48,2109.82,,,,,,PROTECTER FINGER 1 1/2,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,346.62,50,3116.59,,,,,,PROTECTOR FINGER LG 3,,0270,,7.14,5.355,5.355
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,6.25,0.68,2868.2,,,,,,PROTECTOR HEEL & ELBOW,,0270,,13.61,10.2075,10.2075
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,33.74,13.53,65.14,,,,,,PUMP BREAST,,0270,,49.8,37.35,37.35
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,15.2,7.8,30.4,,,,,,PUNCH BIOPSY 3MM,,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,8.33,1.72,16.28,,,,,,QUICKTRACH TRACH TUBE 4.0MM,,0270,,228.55,171.4125,171.4125
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.14,2.07,19.9,,,,,,REMOVER STAPLE/SKIN,,0272,,6.68,5.01,5.01
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.3,5.3,61.31,,,,,,RESERVOIR JACKSON PRA,,0272,,11.92,8.94,8.94
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,RESTRAINT WRIST (PAIR),,0270,,12.79,9.5925,9.5925
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,0,45.56,141.93,,,,,,RHINO ROCKET SLIMLINE LARGE,,0272,,38.51,28.8825,28.8825
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,RHINO ROCKET SLIMLINE MEDIUM,,0272,,42.04,31.53,31.53
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,TUBE SALEM SUMP W/ANTI REFL 14 FR.,,0272,,13.79,10.3425,10.3425
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,TUBE SALEM SUMP W/ANTI REFL 18 FR.,,0272,,13.34,10.005,10.005
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,SCALPEL HARMONIC HAR36,,0272,,608.53,456.3975,456.3975
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,794,Newborn with significant problems,29.9,22.43,22.43,1000.32,1000.32,1000.32,,,,,,SCAPEL SIZE 20,,0272,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,6313.87,4735.4,4735.4,1793.32,1793.32,1793.32,,,,,,SCALPEL SIZE 10,,0272,,6.09,4.5675,4.5675
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.77,2.44,580.94,,,,,,SCALPEL SIZE 11,,0272,,5.37,4.0275,4.0275
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,113.33,32.67,218.78,,,,,,SCALPEL SIZE 15,,0272,,6.05,4.5375,4.5375
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,136.8,94.25,222.4,,,,,,SECONDARY,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,136.8,57.76,225,,,,,,SENSOR SPO2 INFANT MASIMO,,0270,,27.49,20.6175,20.6175
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,136.8,94.25,214.2,,,,,,SENSOR ADULT LNOP MASIMO,,0270,,24.76,18.57,18.57
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],1046.4,784.8,784.8,636.21,350.85,636.21,,,,,,SENSOR PEDI MASIMO,,0270,,24.76,18.57,18.57
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,397.57,137.3,529.3,,,,,,SET SNARE POLYPECTOMY,,0270,,37.69,28.2675,28.2675
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,97.89,8.49,161,,,,,,SHEET THREE QUARTER,,0270,,86.38,64.785,64.785
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.57,8.87,355.2,,,,,,SHOE POST-OP LG-FEMALE,,0270,,18.31,13.7325,13.7325
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,181,14.4,297.7,,,,,,SHOE POST-OP LG-MEN,,0270,,18.31,13.7325,13.7325
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,189.09,63.16,518.42,,,,,,SHOE POST-OP MED-MEN,,0270,,22.26,16.695,16.695
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,0,2.66,76.2,,,,,,SHOE POST-OP MED-WOMEN,,0270,,24.97,18.7275,18.7275
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,82247,Lab analysis to measure the total bilirubin level [HCPCS 82247],118.1,88.58,88.58,32.22,4.22,50.4,,,,,,SHOE POST-OP SM-MEN,,0270,,18.31,13.7325,13.7325
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,50.95,10.81,66.12,,,,,,SHOE POST-OP SM-WOMEN,,0270,,23.62,17.715,17.715
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,67.72,8.16,104.31,,,,,,SHOULDER IMMOB XXL NEO,,0270,,25.34,19.005,19.005
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,84030,"Lab analysis to measure the phenylalanine, PKU (amino acid) level in blood specimen [HCPCS 84030]",102.6,76.95,76.95,29.9,4.62,77.09,,,,,,SHOULDER IMMOBILIZER-LG,,0270,,23.37,17.5275,17.5275
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,79.33,14.11,134.34,,,,,,SHOULDER IMMOBILIZER- SM,,0270,,23.37,17.5275,17.5275
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,39.58,4.35,39.58,,,,,,SHOULDER IMMOBILIZER-MED,,0270,,23.37,17.5275,17.5275
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.63,6,88.2,,,,,,SHOULDER IMMOBILIZER-XLG,,0270,,23.37,17.5275,17.5275
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,36.1,4.34,61.8,,,,,,SLEEVE SCD-SM,,0270,,109,81.75,81.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,70.92,11.52,121.3,,,,,,SLING ARM X-SM,,0270,,12.6,9.45,9.45
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,54.83,16.62,74.01,,,,,,SLING ARM-LG,,0270,,15.43,11.5725,11.5725
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,58.7,6.79,100.4,,,,,,SLING ARM MED,,0270,,15.21,11.4075,11.4075
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,41.59,5.57,65.1,,,,,,SLING ARM-SM,,0270,,14.24,10.68,10.68
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,63.18,2.84,108.1,,,,,,SLING ARM-XLG,,0270,,13.96,10.47,10.47
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,100.57,7.27,172,,,,,,SPECIPAN,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,90.93,29.48,155.5,,,,,,SPECULUM VAGINAL-LG,,0270,,6.01,4.5075,4.5075
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,90.93,29.48,155.5,,,,,,SPECULUM VAGINAL-SM,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,271.53,28.6,1161.38,,,,,,SPIROMETER INCENTIVE,,0270,,9.06,6.795,6.795
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,46.94,16.26,2475.42,,,,,,SPLINT ALUMINUM FINGER 1,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,47.67,4.51,1156.79,,,,,,SPLINT ALUMIUM FINGER 2,,0270,,5,3.75,3.75
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,234.02,61.48,2109.82,,,,,,SPLINT CLAVICLE X-LG,,0270,,20.96,15.72,15.72
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,346.62,50,3116.59,,,,,,SPLINT ANKLE LG,,0270,,31.22,23.415,23.415
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,17.68,5.49,347.63,,,,,,SPLINT ANKLE MED,,0270,,31.22,23.415,23.415
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,J3410,Hydroxyzine hcl injection [HCPCS J3410],33.38,25.04,25.04,20.29,20.29,20.29,,,,,,SPLINT BASEBALL-LG,,0270,,7.88,5.91,5.91
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,21.28,0.02,4433.9,,,,,,SPLINT BASEBALL-SM,,0270,,6.3,4.725,4.725
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,3.36,3.36,245.34,,,,,,SPLINT CLAVICLE SMALL,,0270,,15.93,11.9475,11.9475
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,140.8,79.43,766.3,,,,,,SPLINT CLAVICLE-LG,,0270,,18.52,13.89,13.89
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,1078.01,583.91,1462.85,,,,,,SPLINT CLAVICLE-MED,,0270,,15.93,11.9475,11.9475
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,93.5,59.99,274.04,,,,,,SPLINT ELBOW-ADT(SMALL),,0270,,14.84,11.13,11.13
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,77,77,101.03,,,,,,SPLINT ELBOW-MED,,0270,,26.31,19.7325,19.7325
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,SPLINT ELBOW-SM,,0270,,26.31,19.7325,19.7325
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,SPLINT FINGER 7 7/8,,0270,,5,3.75,3.75
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,SPLINT FINGER 6 ALUM,,0270,,5.25,3.9375,3.9375
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,SPLINT FOREARM MED-LF,,0270,,18.81,14.1075,14.1075
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.12,1.1,17.76,,,,,,SPLINT FOREARM MED-RT,,0270,,18.81,14.1075,14.1075
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,SPLINT FOREARM CHILD LF,,0270,,15.93,11.9475,11.9475
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,69.25,52.38,170.1,,,,,,SPLINT FOREARM CHILD RT,,0270,,15.93,11.9475,11.9475
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,94.21,52.53,206.9,,,,,,SPLINT FOREARM ADULT LF,,0270,,25.59,19.1925,19.1925
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,130.46,95.05,222.03,,,,,,SPLINT FOREARM ADULT RT,,0270,,28.32,21.24,21.24
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.2,31.68,51.15,,,,,,SPLINT KNEE (YOUTH/SM ADULT) TIBIA/FIBU,,0270,,71.19,53.3925,53.3925
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,68.96,45.48,91.29,,,,,,SPLINT KNEE-T/F ADULT LONG,,0270,,76.73,57.5475,57.5475
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,124.75,114.76,176.55,,,,,,SPLINT LEWIN FINGER,,0270,,28.74,21.555,21.555
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.58,59.99,274.04,,,,,,SPLINT LEWIN THUMB,,0270,,25.28,18.96,18.96
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",333,249.75,249.75,70.49,69.22,77.17,,,,,,SPLINT T/F MED KNEE,,0270,,64.14,48.105,48.105
UNITEDHEALTHCARE - Commercial-HMO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,0,91.42,145.6,,,,,,SPLINT T/F SMALL KNEE,,0270,,58.49,43.8675,43.8675
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.14,2.07,19.9,,,,,,SPLINT WRIST LFT-LG,,0270,,25.15,18.8625,18.8625
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.3,5.3,61.31,,,,,,SPLINT WRIST LFT-MED,,0270,,25.65,19.2375,19.2375
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,14,12.82,82,,,,,,SPLINT WRIST LFT-SM,,0270,,20.72,15.54,15.54
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,SPLINT WRIST XL LEFT,,0270,,20.72,15.54,15.54
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,SPLINT WRIST RT-LG,,0270,,23.67,17.7525,17.7525
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,111.4,45.56,141.93,,,,,,SPLINT WRIST XL RIGHT,,0270,,20.72,15.54,15.54
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,131.45,91.42,145.6,,,,,,SPLINT WRIST RT-MED,,0270,,25.29,18.9675,18.9675
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,SPLINT WRIST RT-SM,,0270,,24.46,18.345,18.345
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,SPONGE DRAIN 4 X 4 (6 PLY),,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,SPONGE LAP 18X18(do not use),,0270,,5.86,4.395,4.395
UNITEDHEALTHCARE - Commercial-PPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,SPONGE X-RAY,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,580.94,2.44,580.94,,,,,,SPONGE 2X2 8 PLY,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,256.09,166.13,421.2,,,,,,SPONGE 4X4 16PLY,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,284.97,137.3,401.67,,,,,,SPONGE 4X4 12 PLY,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,397.56,107.93,965.26,,,,,,STAPLER 60MM PROXI RELOADER TX60G,,0272,,152.44,114.33,114.33
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",653.9,490.43,490.43,397.57,137.3,397.57,,,,,,STAPLER LINEAR RELOAD 30MM 3.5MM,,0272,,87.48,65.61,65.61
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,82365,Lab analysis to identify chemicals in kidney stone by infrared spectroscopy [HCPCS 82365],189.7,142.28,142.28,115.34,115.34,115.34,,,,,,STAPLER CUTTER CS40B,,0272,,619.89,464.9175,464.9175
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,188.42,56.58,188.42,,,,,,STAPLER MULTI 20 EMS ENDOPATH,,0272,,217.88,163.41,163.41
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,70.47,8.16,104.31,,,,,,STAPLER INTERNAL 55MM,,0272,,87.99,65.9925,65.9925
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,79.1,7.58,134.6,,,,,,STAPLER PROXI 60MM TX,,0272,,171.35,128.5125,128.5125
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,85.85,12.64,85.85,,,,,,STAPLER PROXIE CRVD TX30B,,0272,,150.27,112.7025,112.7025
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,496.86,7.24,496.86,,,,,,STAPLER PROXIE ILS CR,,0272,,412.89,309.6675,309.6675
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,21.52,4.29,35.67,,,,,,STAPLER PROXIMATE CUR,,0272,,380.23,285.1725,285.1725
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,100.56,45.82,378.9,,,,,,STAPLER PROXIMATE REL,,0272,,80.32,60.24,60.24
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,4344.87,6.15,4344.87,,,,,,STAPLER RELOAD CR40G,,0272,,364.49,273.3675,273.3675
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,1092.27,166.13,1092.27,,,,,,RELOAD CARTRIDGE 55MM TCR55,,0270,,87.99,65.9925,65.9925
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,STAPLER RELOAD CART 55MM TRT55 GREEN DRA,,0272,,87.99,65.9925,65.9925
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,2109.82,61.48,2109.82,,,,,,STAPLER RELOAD PROXIMATE XR60B BLUE,,0272,,80.32,60.24,60.24
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,749.75,50,3116.59,,,,,,STAPLER SKIN 35R,,0272,,14.96,11.22,11.22
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2868.2,0.68,2868.2,,,,,,STAPLER SKIN DS-15,,0272,,14.51,10.8825,10.8825
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,274.57,0.11,332.88,,,,,,SUPPORT LUMBAR UNIVERSAL,,0270,,41.23,30.9225,30.9225
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,2477.89,0.95,3583.7,,,,,,DRESSING TRACHEOSTOMY 4 X 4,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Commercial-PPO,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,297.19,1.29,348.28,,,,,,STAPLES INTERNAL 75MM,,0272,,204.17,153.1275,153.1275
UNITEDHEALTHCARE - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1965,Anesthesia provided during incomplete or missed abortion [HCPCS 01965],139,104.25,104.25,396,396,396,,,,,,STOPCOCK THREEWAY W/RO,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59820,First trimester missed abortion treatment [HCPCS 59820],627.4,470.55,470.55,471.91,471.91,471.91,,,,,,STOPCOCK 3-WAY IV SET,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,STYLETT 10 FR.,,0270,,6.66,4.995,4.995
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,171.4,119.94,617.26,,,,,,STYLETT 14FR,,0270,,7.12,5.34,5.34
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,142.73,20.71,250.4,,,,,,SUCTION CATH 5/6 FR,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,0,8.87,355.2,,,,,,SUCTION CATHETER 10FR,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43.43,2.66,76.2,,,,,,SUCTION CATHETER 12FR,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,160.91,32.98,268.8,,,,,,SUCTION CATHETER 14FR,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,80.48,9.87,141.2,,,,,,SUCTION CATHETER 18FR,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,50.27,6,88.2,,,,,,SUCTION CATHETER 8FR,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,109.38,8.55,182.7,,,,,,SUCTION LINER SMALL 1500,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,0,2.84,108.1,,,,,,SUCTION LINER LARGE 3000cc,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,94.28,45.82,378.9,,,,,,SUCTION POOLE SURGICAL,,0272,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.83,6.15,4344.87,,,,,,SUCTION YANKAUER,,0270,,5,3.75,3.75
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,254.56,68.61,524.17,,,,,,SUPPORT LUMBOSACRAL XXX-LG,,0270,,41.96,31.47,31.47
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.63,12.56,48.28,,,,,,SUPPORT LUMBOSACRAL SMALL,,0270,,41.51,31.1325,31.1325
UNITEDHEALTHCARE - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,533.58,62.92,1098.7,,,,,,SUPPORT LUMBOSACRAL - MD,,0270,,41.21,30.9075,30.9075
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,SUPPORT LUMBOSACRAL-LG,,0270,,43.02,32.265,32.265
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,0,137.3,1347.57,,,,,,SUPPORT LUMBOSACRAL XX-LARGE,,0270,,39.53,29.6475,29.6475
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,0,20.71,250.4,,,,,,SUPPORT LUMOBOSACARAL X-LG,,0270,,43.94,32.955,32.955
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,0,8.87,355.2,,,,,,"SUTURE, 4-0 CHROMIC U203H GUT DOUBLE",,0272,,10.47,7.8525,7.8525
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],99.3,74.48,74.48,0,13.12,94.5,,,,,,"SUTURE, 0 CHROMIC 812H GUT",,0272,,9.97,7.4775,7.4775
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,0,14.4,297.7,,,,,,"SUTURE, 0 CHROMIC 47T LIVER",,0272,,20.12,15.09,15.09
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,9.42,73.71,,,,,,"SUTURE, 0 CHROMIC 812H",,0272,,8.2,6.15,6.15
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,0,9.63,285.09,,,,,,"SUTURE, 2-0 CHROMIC G123H",,0272,,8.46,6.345,6.345
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,0,2.66,76.2,,,,,,"SUTURE, 3-0 CHROMIC L112G",,0272,,10.43,7.8225,7.8225
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,0,6.2,81.6,,,,,,"SUTURE, CHROMIC 3-0 G122H",,0272,,9.06,6.795,6.795
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,0,5.81,65.1,,,,,,"SUTURE,4-0 CHROMIC G121 H",,0272,,10.35,7.7625,7.7625
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,0,11.55,98.31,,,,,,"SUTURE, 4-0 ETHILON 1667G",,0272,,11.33,8.4975,8.4975
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,0,9.72,190.22,,,,,,"SUTURE, 5-0 ETHILON 1666G",,0272,,11.31,8.4825,8.4825
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,0,7.58,134.6,,,,,,"SUTURE, 6-0 ETHILON 1956G",,0272,,13.41,10.0575,10.0575
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,0,14.11,134.34,,,,,,"SUTURE, SILK 0 K844H",,0272,,9.97,7.4775,7.4775
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,9.87,141.2,,,,,,"SUTURE, LIGACLIP LRG. LS- 400",,0272,,44.01,33.0075,33.0075
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,0,6,88.2,,,,,,"SUTURE, LIGACLIP MED. LT-200",,0272,,9.56,7.17,7.17
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,0,8.55,182.7,,,,,,"SUTURE, RMS MERSILENE MESH",,0272,,89.14,66.855,66.855
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,0,2.84,108.1,,,,,,"SUTURE, 0 MERSILENE MR21T",,0272,,28.82,21.615,21.615
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,0,45.82,378.9,,,,,,"SUTURE, PMH MESH PROLENE",,0272,,84.25,63.1875,63.1875
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,0,6.15,4344.87,,,,,,"SUTURE, 2-0 PROLENE PDSIII Z114H",,0272,,188.31,141.2325,141.2325
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,"SUTURE, 2-0 PROLENE 8623H",,0272,,8.02,6.015,6.015
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,0,68.61,524.17,,,,,,"SUTURE, 2-0 PROLENE 8825G",,0272,,80.84,60.63,60.63
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,0,20.72,3197.1,,,,,,"SUTURE, 2-0 PROLENE 8833H",,0272,,150.17,112.6275,112.6275
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,0,12.56,48.28,,,,,,TROCAR 8MM(owens&minor) ENDOPATH EXCEL,,0272,,155.17,116.3775,116.3775
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,0,62.92,1098.7,,,,,,"SUTURE, 0 PROLENE 8834H",,0272,,9.09,6.8175,6.8175
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,0,0.68,2868.2,,,,,,"SUTURE,450G RETENTION SUTURE BRIDGE",,0272,,6.51,4.8825,4.8825
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,0,7.08,29.34,,,,,,"SUTURE, RSB5 RETENTION SUTURE BRIDGE",,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,0,52.38,170.1,,,,,,"SUTURE, 0 SILK SA86G",,0272,,6.82,5.115,5.115
UNITEDHEALTHCARE COMMUNITY PLAN OF KY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,0,52.53,206.9,,,,,,"SUTURE, 3-0 SILK SA84H",,0272,,6.7,5.025,5.025
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.73,2.44,580.94,,,,,,"SUTURE, 5-0 SILK K890H",,0272,,9.83,7.3725,7.3725
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,147.23,28.74,271.3,,,,,,TAPE UMBILICAL COTTON 1/8X18,,0270,,5,3.75,3.75
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,87.38,8.49,161,,,,,,"SUTURE, 0 VICRYL J207G",,0272,,6.01,4.5075,4.5075
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,137.42,8.87,355.2,,,,,,"SUTURE, 0 VICRYL J346H",,0272,,5,3.75,3.75
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,0,11.25,148.9,,,,,,"SUTURE, 0 VICRYL J603H",,0272,,5.29,3.9675,3.9675
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,100.55,8.3,183.45,,,,,,"SUTURE, 0 VICRYL J946H(do not use)",,0272,,5.26,3.945,3.945
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,41.33,2.66,76.2,,,,,,"SUTURE, VICRYL 3-0 J790D",,0272,,30.67,23.0025,23.0025
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,70.62,7.58,134.6,,,,,,SUTURE 0 MAXON 6269-61,,0272,,16.14,12.105,12.105
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,73.64,14.11,134.34,,,,,,SUTURE 0 SILK K834H,,0272,,5,3.75,3.75
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.26,6,88.2,,,,,,SUTURE 0 VICRYL J340 H,,0272,,5.04,3.78,3.78
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,20.35,5.43,37.5,,,,,,SUTURE 10-0 ETHILON 9000G,,0272,,39.79,29.8425,29.8425
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,37.05,2.7,54.33,,,,,,"SUTURE, 2-0 MERSILENE R496T",,0272,,14.33,10.7475,10.7475
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,84.42,12.29,258.33,,,,,,SUTURE 2-0 CHROMIC 816H,,0272,,9.29,6.9675,6.9675
"AMA INSURANCE AGENCY, INC. - Medicare Part A",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,66.46,6.15,4344.87,,,,,,SUTURE 2-0 CHROMIC 637G,,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,0,35.11,337.46,,,,,,SUTURE 2-0 CHROMIC L113 G,,0272,,10.75,8.0625,8.0625
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Clinic,Institutional,Outpatient,T1015,Clinic service [HCPCS T1015],105.91,79.43,79.43,0,240.69,245.75,,,,,,SUTURE 2-0 CHROMIC N878 H,,0272,,11.68,8.76,8.76
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,SUTURE 2-0 DEXON 9232-51,,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,0,55,3102.09,,,,,,SUTURE 2-0 ETHILON 664 G,,0272,,5.57,4.1775,4.1775
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,SUTURE 2-0 MAXON 6269-51,,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,70100,"Lower jaw x-ray, partial study (less than 4 views) [HCPCS 70100]",228.3,171.23,171.23,0,123.34,123.34,,,,,,SUTURE 2-0 PROLENE 8833H,,0272,,9.11,6.8325,6.8325
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,137.3,137.3,1347.57,,,,,,SUTURE 2-0 PROLENE 8685H,,0272,,7.43,5.5725,5.5725
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,137.3,73.48,1221.85,,,,,,SUTURE 2-0 SA5H SILK FREE,,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,0,4.45,148.78,,,,,,SUTURE 2-0 SILK K833H,,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,101.93,69.84,225,,,,,,SUTURE 2-0 SILK SA85H,,0272,,108.45,81.3375,81.3375
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,39.88,37.7,213.75,,,,,,SUTURE 2-0 VICRYL J345H,,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,137.3,137.3,401.67,,,,,,SUTURE 2-0 VICRYL J785G,,0272,,25.4,19.05,19.05
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,0,8.49,161,,,,,,SUTURE 2-0 VICRYL J417 H,,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,8.87,8.87,355.2,,,,,,SUTURE 2-0 VICRYL J945H,,0272,,13.81,10.3575,10.3575
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,0,11.25,148.9,,,,,,"SUTURE, 3-0 CHROMIC 636H",,0272,,8.57,6.4275,6.4275
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,0,63.16,518.42,,,,,,"SUTURE, 3-0 ETHILON 1663G",,0272,,12.37,9.2775,9.2775
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,2.66,2.66,76.2,,,,,,"SUTURE, 3-0 MERSILENE R832H",,0272,,6.62,4.965,4.965
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,1.89,1.89,53,,,,,,"SUTURE, 3-0 PLAIN G322H",,0272,,9.97,7.4775,7.4775
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,7.23,6.2,81.6,,,,,,"SUTURE, 3-0 PLAIN G822H",,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,0,8.16,104.31,,,,,,"SUTURE, 3-0 PLAIN GUT (842H)",,0272,,8.66,6.495,6.495
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,0,11.58,453.2,,,,,,"SUTURE, 3-0 SILK K832H",,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,14.11,14.11,134.34,,,,,,"SUTURE, 3-0 SILK 1684G",,0272,,11.15,8.3625,8.3625
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,6.53,6,88.2,,,,,,"SUTURE, 3-0 VICRYL J316H",,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,0,12.29,258.33,,,,,,"SUTURE, 3-0 VICRYL J205G",,0272,,6.07,4.5525,4.5525
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,0,12.2,112.96,,,,,,"SUTURE, 3-0 VICRYL J497H",,0272,,11.4,8.55,8.55
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,0,18.22,199.4,,,,,,"SUTURE, 3-0 VICRYL J784G",,0272,,25.11,18.8325,18.8325
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,0,12.25,187.04,,,,,,"SUTURE, 3-0 VICRYL J944H",,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,0,14.79,121.3,,,,,,"SUTURE, 4-0 CHROMIC 635H",,0272,,8.12,6.09,6.09
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,0,5.76,186.4,,,,,,"SUTURE, 4-0 PLAIN H821G",,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,7.24,7.24,496.86,,,,,,"SUTURE, 4-0 PROLENE 8683G",,0272,,8.04,6.03,6.03
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,6.79,6.79,100.4,,,,,,"SUTURE, 4-0 SILK K831H",,0272,,5,3.75,3.75
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,6.78,2.84,108.1,,,,,,"SUTURE, 4-0 SILK K952H",,0272,,8.76,6.57,6.57
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,7.27,7.27,172,,,,,,"SUTURE, 4-0 SILK N272H",,0272,,7.75,5.8125,5.8125
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,11.87,8.17,155.5,,,,,,"SUTURE, 4-0 SILK 1677G",,0272,,10.1,7.575,7.575
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,11.68,11.68,116.85,,,,,,"SUTURE, 4-0 VICRYL J783G",,0272,,25.07,18.8025,18.8025
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,14.12,14.12,74.6,,,,,,"SUTURE, 5-0 CHROMIC 634G",,0272,,10.44,7.83,7.83
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,"SUTURE, 5-0 PROLENE 8698G",,0272,,14.24,10.68,10.68
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,29.48,29.48,105,,,,,,"SUTURE, 5-0 SILK A182H",,0272,,5.2,3.9,3.9
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,0,19.15,448.97,,,,,,"SUTURE, 5-0 SILK N271H",,0272,,8.18,6.135,6.135
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,0,4.51,1156.79,,,,,,"SUTURE, 5-0 SILK 1676G",,0272,,10.2,7.65,7.65
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,0,39.1,434.06,,,,,,"SUTURE, 5-0 SILK 1780G",,0272,,25.95,19.4625,19.4625
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,242.68,61.48,2109.82,,,,,,"SUTURE, 6-0 CHROMIC 1791G",,0272,,36.62,27.465,27.465
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,553,50,3116.59,,,,,,"SUTURE, 6-0 ETHILON 1665G",,0272,,10.6,7.95,7.95
UNITEDHEALTHCARE COMMUNITY PLAN OF TEXAS - Medicaid,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,1.68,0.11,332.88,,,,,,"SUTURE, 6-0 PROLENE 8709H",,0272,,29.74,22.305,22.305
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,0,131.45,310.8,,,,,,"SUTURE, 6-0 PROLENE 8695G",,0272,,14.6,10.95,10.95
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,0,55,3102.09,,,,,,"SUTURE, 3-0 CHROMIC 810H",,0272,,178.68,134.01,134.01
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.99,2.44,580.94,,,,,,"SUTURE,2-0 CHROMIC 811H",,0272,,9.68,7.26,7.26
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,77.72,20.71,250.4,,,,,,"SUTURE,4-0 VICRYL J496H",,0272,,11.33,8.4975,8.4975
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,0,109.96,166.13,,,,,,SWAB BENZOIN(discontinued do not use),,0270,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,69.84,69.84,223.7,,,,,,"SWAB, BETADINE (3pk)",,0270,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,69.84,69.84,225,,,,,,"SWAB, LEMON",,0270,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,0,561.23,2500,,,,,,"SYRINGE, EAR BULB",,0270,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,0,41.68,551.29,,,,,,"SYRINGE, EAR BULB RED OR",,0270,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.56,8.87,355.2,,,,,,"SYRINGE, IRRIGATION 60CC",,0270,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,17.14,14.4,297.7,,,,,,"SYRINGE, IRRIGATION",,0270,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.17,2.66,76.2,,,,,,SYRINGE(BAYER) POWER INJECTOR,,0270,,32.26,24.195,24.195
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,3.28,2.09,3.53,,,,,,"SYRINGE, TB WITH NEEDLE",,,,,,
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,0,1.89,53,,,,,,"SYRINGE,3CC",,,,,,
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,8.15,6.2,81.6,,,,,,TAPE MICROFOAM 3,,,,,,
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,0,5.44,96,,,,,,TAPE. ELASTOPLAST 4,,,,,,
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,0,5.81,65.1,,,,,,"TAPE, MEDIPORE 2X10",,0270,,12.24,9.18,9.18
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,0,11.55,98.31,,,,,,TED HOSE-LG,,0270,,14.93,11.1975,11.1975
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,11.57,9.72,190.22,,,,,,TED HOSE-MED,,0270,,14.77,11.0775,11.0775
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,0,5,105.9,,,,,,TED HOSE-SM THIGH LENGTH,,0270,,25.72,19.29,19.29
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,0,32.98,268.8,,,,,,DRESSING TEGADERM AG SILVER MESH P.T.,,0270,,24.42,18.315,18.315
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,16.8,14.11,134.34,,,,,,"TELEMETRY, PACK SUPPLY",,0272,,5.77,4.3275,4.3275
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,9.87,141.2,,,,,,TEXAS CATHETER,,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.77,6,88.2,,,,,,TOOTHPASTE,,,,,,
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,0,8.55,182.7,,,,,,"TRAP, MUCOUS SPECIMEN",,0270,,5.37,4.0275,4.0275
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,0,7.24,496.86,,,,,,TRAY SUPRA FOLEY 12 FR,,0272,,163.61,122.7075,122.7075
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,0,9.38,86.39,,,,,,"TRAY, CATHETER 16FR (LATEX)",,0272,,29.31,21.9825,21.9825
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,0,6.79,100.4,,,,,,TRAY CATHETER LATEX 14FR (OM),,0272,,28.77,21.5775,21.5775
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,8.07,2.84,108.1,,,,,,"TRAY, CATHETER 18FR. (CARDINAL)",,0272,,27.32,20.49,20.49
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,8.09,6.8,52.43,,,,,,"TRAY, EPIDURAL(BRAUN)",,0272,,46.39,34.7925,34.7925
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,0,7.27,172,,,,,,"TRAY, LUMBAR PUNC/INFANT",,0272,,20.73,15.5475,15.5475
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,0,4.29,39.3,,,,,,"TRAY, LUMBAR PUNCT-ADT",,0272,,25.37,19.0275,19.0275
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,9.08,8.17,155.5,,,,,,"TRAY, LUMBAR PUNCTURE PEDI 21G",,0272,,21.15,15.8625,15.8625
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,70.2,58.97,116.37,,,,,,"TRAY, PARACERVICAL BLOCK",,0272,,70.91,53.1825,53.1825
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,"TRAY, SKIN PREP",,0272,,11.28,8.46,8.46
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,35.09,29.48,105,,,,,,"TRAY, SPINAL ANESTHESIA W/BUPIVACAINE",,0272,,33.87,25.4025,25.4025
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,0,6.15,4344.87,,,,,,"TRAY, THORACENTESIS",,0272,,31.94,23.955,23.955
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,"TRAY, TRACHEOSTOMY KIT",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,"TRAY, URETHRAL 16fr",,0272,,6.22,4.665,4.665
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,0,4.51,1156.79,,,,,,"TRAY, URIMETER",,0272,,21.64,16.23,16.23
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,TROCAR XCEL B12LT,,0272,,44.4,33.3,33.3
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,0,12.56,48.28,,,,,,TROCAR XCEL B5LT,,0272,,44.4,33.3,33.3
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,75.99,39.1,434.06,,,,,,TROCAR XCEL 12MM H12LP,,0272,,44.4,33.3,33.3
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,119.47,61.48,2109.82,,,,,,TUBE MEDIHONEY 41GM,,0270,,27.84,20.88,20.88
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,176.96,50,3116.59,,,,,,"TUBE, E.T. 2.5",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,0,0.68,2868.2,,,,,,"TUBE, E.T. 3.0",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,0,0.11,332.88,,,,,,"TUBE, E.T. 3.5",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0,0.73,808.23,,,,,,"TUBE, E.T. 4.0",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,0,0.95,3583.7,,,,,,"TUBE, E.T. 4.5",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF LOUISIANA INC - Medicaid,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,7.76,2.81,811.33,,,,,,"TUBE, E.T. 5.0",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,21,2.44,580.94,,,,,,"TUBE, E.T. 5.5",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,2489.5,180.22,3324.06,,,,,,"TUBE, E.T. 6.0",,0272,,5.8,4.35,4.35
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,246,8.87,355.2,,,,,,"TUBE, E.T. 6.5",,0272,,5.49,4.1175,4.1175
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,76.2,2.66,76.2,,,,,,"TUBE, E.T. 7.0",,0272,,5.22,3.915,3.915
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,81.6,6.2,81.6,,,,,,"TUBE, E.T. 8.0",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,96,5.44,96,,,,,,"TUBE, E.T. 8.5",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,105.9,5,105.9,,,,,,"TUBE, E.T. 9.0",,0270,,6.56,4.92,4.92
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,88.2,6,88.2,,,,,,"TUBE, E.T. 7.5",,0272,,5.18,3.885,3.885
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,100.4,6.79,100.4,,,,,,"TUBE, ET W/STYLETTE 3.0",,0272,,11.03,8.2725,8.2725
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,108.1,2.84,108.1,,,,,,"TUBE, ET W/STYLETTE 2.5",,0272,,11.03,8.2725,8.2725
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,24.8,6.8,52.43,,,,,,"TUBE, ET W/STYLETTE 3.5",,0272,,11.03,8.2725,8.2725
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,172,7.27,172,,,,,,"TUBE, ET W/STYLETTE 4.0",,0272,,11.03,8.2725,8.2725
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,199.6,29.4,2785.69,,,,,,"TUBE, FEEDING 5 FR",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,39.7,12.56,48.28,,,,,,"TUBE, FEEDING 8FR.",,0272,,5,3.75,3.75
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,570.1,50,3116.59,,,,,,"TUBE, LEVIN SZ 12",,0272,,5.25,3.9375,3.9375
UNITEDHEALTHCARE OF TEXAS INC - Commercial-EPO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,6.25,0.68,2868.2,,,,,,"TUBE, LEVIN SZ 14",,0272,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.14,2.07,19.9,,,,,,"TUBE, LEVIN SZ 16",,0272,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,14,12.82,82,,,,,,"TUBE, LEVIN 10FR",,0272,,5.83,4.3725,4.3725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,10.06,1.28,46.3,,,,,,TUBE SALEM SUMP REF 16 FR.,,0272,,7.93,5.9475,5.9475
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,21.35,15.77,25,,,,,,"TUBE, SET/IRRIGATE EPT03",,0272,,31.23,23.4225,23.4225
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,"TUBE, TRACH 6MM(OWENSNMINOR)",,0272,,55.83,41.8725,41.8725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,89.65,45.56,141.93,,,,,,"TUBE, TRACH 8MM(OWENSNMINOR)",,0272,,42.13,31.5975,31.5975
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,131.45,91.42,145.6,,,,,,"TUBE, TRACHEOSTOMY 5",,0272,,55.83,41.8725,41.8725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,200.2,140.39,202.54,,,,,,"TUBE,GAS SAMPLING",,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,53.91,13.55,72.8,,,,,,"TUBING, AEROSOL",,0272,,15.59,11.6925,11.6925
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,86.35,62.38,245.75,,,,,,"TUBING, CONNECTING (LIGHT BLUE)",,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,129.81,70,166.6,,,,,,"TUBING, INSUFFLATOR",,0272,,36.19,27.1425,27.1425
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,175.45,147.2,226.48,,,,,,LINE C02 CAPILLARY TUBING,,0272,,143.52,107.64,107.64
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,65.1,65.1,245.75,,,,,,"TUBING, VACUUM SUCTION",,0272,,20.7,15.525,15.525
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,ULTRASITE EXT SET (IV),,0272,,11.81,8.8575,8.8575
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.11,1.1,17.76,,,,,,CATH UMBILICAL VESSELL SZ. 3.5,,0272,,7.19,5.3925,5.3925
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Inpatient,100,Seizures with major complications,11693.7,8770.28,8770.28,7179.93,2577.56,7179.93,,,,,,SPECIMAN 24HR. URINAL,,0270,,11.14,8.355,8.355
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Inpatient,700,Other kidney & urinary tract diagnoses without complications,3271.46,2453.6,2453.6,8584.81,42.53,8584.81,,,,,,VALVE ULTRASITE MALE LUER ER O,,0270,,6.1,4.575,4.575
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,76.79,55,3102.09,,,,,,VENI LOOP I/V,,0272,,6.48,4.86,4.86
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,12.76,2.44,580.94,,,,,,WATER 1000ML STERILE IRR,,0270,,5.14,3.855,3.855
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,919.34,137.3,1347.57,,,,,,WATER 250ML STERILE IRR,,0270,,5.02,3.765,3.765
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,152.24,20.71,250.4,,,,,,WIPE FILM BARRIER,,,,,,
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,136.82,69.84,223.7,,,,,,WRAP E-Z 2 RESP CARE,,,,,,
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,136.85,94.25,222.4,,,,,,PAPER 100MM LIFEPAK,,,,,,
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",225,168.75,168.75,136.8,94.25,180,,,,,,SPECULUM MED,,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,176.38,73.09,246.59,,,,,,PREP CHLORA 3ML(donotuse discontinued per vendor),,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,136.8,56.37,178.99,,,,,,EXT. SET W/CLEARLOCK,,0270,,8.08,6.06,6.06
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,136.84,31.41,166.13,,,,,,SLING ARM XX-SMALL,,0270,,11.46,8.595,8.595
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,74022,"Abdominal x-ray, complete study including 2 or more views of abdomen and single view of chest [HCPCS 74022]",377.1,282.83,282.83,229.27,158,229.27,,,,,,DETECTOR CO2 PEDI-CAP,,0270,,23.38,17.535,17.535
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1513.61,180.22,3324.06,,,,,,CANNULA INNER DISP.,,0270,,5.84,4.38,4.38
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,397.57,166.13,529.3,,,,,,SUTURE 1-0 VICRYL J741G,,0272,,26.26,19.695,19.695
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,382.33,137.3,529.3,,,,,,SUTURE 1-0 VICRYL J841D,,0272,,7.43,5.5725,5.5725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,408.27,166.13,529.81,,,,,,GOWN(95998) XXXL EX-LG,,0270,,12.11,9.0825,9.0825
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,149.56,8.87,355.2,,,,,,DRAPE LAVH,,0270,,38.89,29.1675,29.1675
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,181,14.4,297.7,,,,,,DRESSING MEPILEX 4 X 4 P.T.,,0272,,11.05,8.2875,8.2875
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,52.28,9.42,73.71,,,,,,DRESSING FOAM MEPULEX AG 4 X 4 P.T.,,0272,,21.65,16.2375,16.2375
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,79.83,9.63,285.09,,,,,,DRESSING TEGADERM ALGINATE AG 6 X 6,,0272,,34.17,25.6275,25.6275
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,46.32,2.66,76.2,,,,,,DRESSING SEASORB SOFT ALIGINATE,,0272,,13.95,10.4625,10.4625
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,32.22,1.89,53,,,,,,TUBE FEEDING 10FR. WITH Y-SITE,,0272,,24.91,18.6825,18.6825
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,49.61,6.2,81.6,,,,,,SUTURE 4-0 CHROMIC GUT L111G,,0272,,11.43,8.5725,8.5725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,58.36,5.44,96,,,,,,CANNULA INNER DISPOSABLE XLT 6.0,,0272,,15.52,11.64,11.64
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,169.58,30.08,290.1,,,,,,CURETTE VACUUM 14MM,,0272,,10.69,8.0175,8.0175
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,39.97,5.81,65.1,,,,,,"NEEDLE INSUFFLATOR PNEUMO 14G,12CM",,0272,,26.45,19.8375,19.8375
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,60.37,11.55,98.31,,,,,,"NEEDLE INSUFFLATOR PNEUNO 14G,15CM",,0272,,26.45,19.8375,19.8375
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,188.42,56.58,188.42,,,,,,BRUSH CYTOLOGY PEDI 2.5 STRT HNDL,,0272,,24.19,18.1425,18.1425
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,70.47,8.16,104.31,,,,,,BRIEF MESH LG (BROWN),,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,118.01,9.72,190.22,,,,,,BRIEF MESH PANT X-L WHITE,,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,64.38,5,105.9,,,,,,DRESSING TEGADERM ALGINATE AG 1 X 12,,0270,,18.97,14.2275,14.2275
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,82.5,14.11,134.34,,,,,,AIRWAY I-GEL SUPRA SZ. 4,,0270,,24.76,18.57,18.57
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,86.69,9.87,141.2,,,,,,AIRWAY I-GEL SUPRA SZ. 3,,0270,,26.14,19.605,19.605
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,32.22,4.54,50.4,,,,,,TUBE E.T. W/ STYLETTE 4.5,,0272,,11.03,8.2725,8.2725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,53.62,6,88.2,,,,,,BAG INFANT RESUSCITATOR W/SAFE SPOT,,0270,,45.45,34.0875,34.0875
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,21.91,5.43,37.5,,,,,,BOWL UTILITY STERILE DR. BANSAL 32 OZ.,,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,42.31,3.6,69.6,,,,,,SUTURE CHROMIC 2 TP-1 60,,0272,,18.49,13.8675,13.8675
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,41.52,2.7,54.33,,,,,,CUFF BLOOD CHILD DISP (2 TUBING),,0270,,20.83,15.6225,15.6225
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,42.31,6.03,69.6,,,,,,NEEDLE HUBER 20G 1/2,,0272,,8.15,6.1125,6.1125
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,46.32,5.26,76.2,,,,,,NEEDLE HUBER 20G 1,,0272,,8.39,6.2925,6.2925
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,113.33,5.76,186.4,,,,,,TROCAR BLADLESS B12XT 12MM X 150MM,,0272,,125.15,93.8625,93.8625
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,82.52,9.2,112.32,,,,,,TROCAR BLADELESS 5MM X 150MM B5XT,,0272,,44.4,33.3,33.3
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,58.02,7.24,496.86,,,,,,DRESSING ELASTO-GEL (N/S),,0270,,9.83,7.3725,7.3725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,86.38,9.38,86.39,,,,,,DRESSING DUODERM XTHIN 4 X 4,,0272,,5.47,4.1025,4.1025
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,58.69,6.79,100.4,,,,,,EXT. SET 8.5 W/PINCH CLAMP,,0272,,7.32,5.49,5.49
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,65.72,2.84,108.1,,,,,,BLADE CLIPPER 9670,,0272,,8.68,6.51,6.51
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,100.57,7.27,172,,,,,,SUCTION LITTLE SUCKER W/COVER,,0272,,9.4,7.05,7.05
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,30.33,4.29,39.3,,,,,,TRANSFER SET W/VALVE AND SPIKE,,0272,,15.72,11.79,11.79
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,94.54,8.17,155.5,,,,,,DRESSING TEGADERM HYDRO 6 3/4x6 3/8,,0272,,19.76,14.82,14.82
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,67.06,37.79,110.3,,,,,,"TRAY, SUTURE REM. SUB",,0272,,5.36,4.02,4.02
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,45.8,14.12,74.6,,,,,,MASK PROCEDURE MASK,,,,,,
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,95.76,58.97,116.37,,,,,,DRESSING AQUACELL EXTRA 6X6,,0272,,22.93,17.1975,17.1975
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,100.56,45.82,378.9,,,,,,LANOLIN TENDERCARE .3oz,,0270,,5.47,4.1025,4.1025
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,63.84,29.48,105,,,,,,DRESSING ADAPTIC 3X8 (2015),,0272,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,20.12,4.29,27.04,,,,,,PEG PUSH SAFETY KIT,,0272,,170.53,127.8975,127.8975
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,75.26,6.15,4344.87,,,,,,TED HOSE-X-LG LONG THIGH,,0270,,15.5,11.625,11.625
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,271.53,28.6,1161.38,,,,,,NORMAL SALINE-SOD CHLO 500ML,,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,59.03,16.26,2475.42,,,,,,DRESSING ALLEVYN GENTLE BORDER HEEL,,0272,,0,,
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,47.67,4.51,1156.79,,,,,,GVL 3 STAT LARYNGOSCOPE,,0272,,42.48,31.86,31.86
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,121.35,29.4,2785.69,,,,,,GVL 4 STAT LARYNGOSCOPE,,0272,,42.48,31.86,31.86
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,24.14,12.56,48.28,,,,,,DRESSING ALLEVYN GENTLE BORDER MULTISITE,,0272,,18.31,13.7325,13.7325
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,68.4,40.84,136.8,,,,,,SUTURE 4-0 POLYSORB 4.0 V-20,,0272,,14.48,10.86,10.86
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,221.92,140.59,428.4,,,,,,SUTURE 2-0 VICRYL PLUS ANTIBACT VCPB259H,,0272,,7.08,5.31,5.31
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,76.75,2.2,117.5,,,,,,SUTURE 0 PDS PLUS CTX PDP370T,,0272,,8.72,6.54,6.54
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,148.84,39.1,434.06,,,,,,SUTURE LIGATURE MERSILENE RS20,,0272,,63.3,47.475,47.475
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,234.01,61.48,2109.82,,,,,,REMOVER STAPLE/SKIN (SUB),,0272,,5.46,4.095,4.095
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,346.62,50,3116.59,,,,,,"DRESSING, AQUACEL AG EXTRA HYDROFIBER",,0272,,14.71,11.0325,11.0325
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,574.76,62.92,1098.7,,,,,,TED HOSE-SM REGULAR LENGTH,,0270,,15.5,11.625,11.625
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,6.75,3.22,2266.54,,,,,,GAUZE VASELINE 3X9,,0272,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,15.27,11,29.34,,,,,,OMNI C-CUP KIWI,,0270,,67.34,50.505,50.505
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J2354,"Octreotide inj, non-depot [HCPCS J2354]",7.46,5.6,5.6,4.53,4.53,4.53,,,,,,OMNI CUP KIWI W/TRACTION FORCE,,0270,,57.83,43.3725,43.3725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.6,0.95,3583.7,,,,,,DRESSING MEDIHONEY 4.5 X 4.5,,0272,,26.02,19.515,19.515
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,15.21,2.81,811.33,,,,,,"SPECIMEN CUP, STERILE W/SEAL",,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,17.68,5.49,347.63,,,,,,PEN MARKING SURG 250PR,,0270,,5,3.75,3.75
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J3475,Inj magnesium sulfate [HCPCS J3475],2.5,1.88,1.88,1.52,1.52,1.52,,,,,,KNEE SUPPORT ELASTIC W/CLOSURES,,0270,,14.23,10.6725,10.6725
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,21.28,0.02,4433.9,,,,,,HIP FOAM SPLINT,,0270,,13.67,10.2525,10.2525
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,96.25,3.36,245.34,,,,,,DRAIN JACKSON PRATT 24FR HUBLESS,,0272,,34.98,26.235,26.235
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1968,Anesthesia provided during cesarean delivery following labor [HCPCS 01968],139,104.25,104.25,68.75,2.99,188.42,,,,,,LIMB WRAPAROUND HOLDER X-STRONG,,0270,,12.78,9.585,9.585
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,0,95.05,222.03,,,,,,SUCKER LITTLE NASAL TIP,,0272,,222.17,166.6275,166.6275
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,248.05,120.14,248.05,,,,,,SKIN CLEANSER ANTISEPTIC SPRAY 8.0 OZ.,,,,,,
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,91.29,45.48,91.29,,,,,,DISPOSABLE SCIEROTHERAPY NEEDLE,,0272,,49.01,36.7575,36.7575
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],257,192.75,192.75,130.9,99.96,130.9,,,,,,DRESSING TEGADERM ABSORBENT,,0272,,7.26,5.445,5.445
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,93.5,59.99,274.04,,,,,,DRESSING VERSIVA GELLING FOAM 4X4,,0272,,12.75,9.5625,9.5625
UNITEDHEALTHCARE SERVICES INC - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,0,33.41,326.4,,,,,,DRESSING TEGADERM ALGINATE 4X4,,0272,,8.88,6.66,6.66
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,303.42,70.45,319.43,,,,,,FILTER LINE SET ADULT/PED,,0272,,24.86,18.645,18.645
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.85,2.44,580.94,,,,,,SENSOR LNCS ADULT MASIMO,,0272,,23.34,17.505,17.505
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,142.73,20.71,250.4,,,,,,SENSOR LNCS PEDIATRIC MASIMO,,0272,,23.43,17.5725,17.5725
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,126.58,24.39,148.78,,,,,,DRESSING AQUACELL 4X5 W/HYDROFIBER,,0272,,12.38,9.285,9.285
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,126.58,18.85,148.78,,,,,,AIRWAY I-GEL SUPRA SZ. 5,,0270,,24.76,18.57,18.57
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,90.85,8.49,161,,,,,,DRESSING ALLEVYN GENTLE BORDER LITE 3X3,,0272,,7.73,5.7975,5.7975
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,140.22,8.87,355.2,,,,,,GEL SILVASORB SILVER .25OZ,,0270,,28.74,21.555,21.555
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43,2.66,76.2,,,,,,DRESSING POWDER ARGLAES 2 GR. BOTTLE,,0272,,25.03,18.7725,18.7725
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,67.32,11.45,112.4,,,,,,DRESSING MEDIHONEY 2x2,,0272,,12.11,9.0825,9.0825
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,88.64,5.07,94.54,,,,,,SENSOR LNCS INFANT MASIMO,,0272,,26.37,19.7775,19.7775
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,79.68,9.87,141.2,,,,,,SENSOR LNCS NEONATAL MASIMO,,0272,,25.86,19.395,19.395
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,HYDROGEL SKINTEGRITY 1 oz.,,0272,,9.38,7.035,7.035
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,109.38,8.55,182.7,,,,,,ROPE WIC SILVER 0.4 X 14 (1814),,0272,,24.47,18.3525,18.3525
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,61,2.84,108.1,,,,,,DRESSING AQUACELL RIBBON 1.0 CM X 45CM,,0272,,33.21,24.9075,24.9075
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,93.34,45.82,378.9,,,,,,DRESSING OPTILOCK NON-ADHESIVE,,0272,,49.16,36.87,36.87
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.38,6.15,4344.87,,,,,,DRESSING OPTIFOAM GENTLE BORDER 4X4,,0272,,10.34,7.755,7.755
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,47.77,16.49,98.36,,,,,,ANTI-FOG OUT SOLUTION W/ FOAM PAD(do not use),,0270,,7.69,5.7675,5.7675
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,43.72,16.26,2475.42,,,,,,ENDOTRACH TUBE FASTNER,,0272,,21.33,15.9975,15.9975
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,201.04,68.61,524.17,,,,,,BOOT PODOUS-REGULAR (UNIVERSAL),,0270,,155.98,116.985,116.985
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,44.11,4.51,1156.79,,,,,,TUBING SMOKE EVACUATOR,,0272,,39.62,29.715,29.715
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,112.29,29.4,2785.69,,,,,,PRE-FILTER SMOKE EVACUATOR,,0272,,43.8,32.85,32.85
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.34,12.56,48.28,,,,,,ELECTRODE LEEP BALL,,0272,,43.39,32.5425,32.5425
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,22.34,10.24,44.01,,,,,,ELECTRODE LEEP SQUARE CONDYLOMA,,0272,,46.65,34.9875,34.9875
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,208.05,140.59,428.4,,,,,,ELECTRODE LEEP RADIUS R2008,,0272,,46.65,34.9875,34.9875
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,137.73,39.1,434.06,,,,,,ELECTRODE LEEP RADIUS R1010,,0272,,46.65,34.9875,34.9875
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,322.85,50,3116.59,,,,,,LEEP REDIKIT,,0270,,70.85,53.1375,53.1375
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,13.85,5.83,3301.98,,,,,,LEEP PATIENT RETURN PAD,,0270,,21.98,16.485,16.485
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,3.54,0.68,2868.2,,,,,,ADAPTOR FOR PATIENT (LEEP),,0270,,91.5,68.625,68.625
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,14.07,3.15,30.39,,,,,,SMOKE EVACUATOR REDUCER,,,,,,
WASHINGTON NATIONAL INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,0,0.02,4433.9,,,,,,SWITCH FOOT PENCIL ELECTROSURGICAL,,,,,,
WASHINGTON NATIONAL INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,68.96,52.38,170.1,,,,,,BRIEF MESH LG (INDIVIDUAL),,0270,,5,3.75,3.75
WASHINGTON NATIONAL INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,94.21,52.53,206.9,,,,,,RELOAD ENDOCUTTER 45MM 6R45B,,0272,,232.34,174.255,174.255
WASHINGTON NATIONAL INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37.3,31.68,51.15,,,,,,STRYKEFLOW 2 WITH TIP,,0272,,101.94,76.455,76.455
WASHINGTON NATIONAL INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,68.96,45.48,91.29,,,,,,COLLAR ADJUSTABLE INFANT AND PEDI,,0270,,13.92,10.44,10.44
WASHINGTON NATIONAL INSURANCE CO - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,101.89,33.41,326.4,,,,,,"TUBE, E.T. 9.0 (COVIDIEN)",,0272,,5,3.75,3.75
WEBTPA EMPLOYER SERVICES - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,KNEE CAP SUPPORT XX-LARGE,,0270,,38.63,28.9725,28.9725
WEBTPA EMPLOYER SERVICES - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,300.05,70.45,319.43,,,,,,"TUBING, INSUFFLATOR HIGH FLOW SET",,0272,,23.83,17.8725,17.8725
WEBTPA EMPLOYER SERVICES - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,344.55,236.82,344.55,,,,,,DRESSING AQUACELL EXTRA AG 6X6,,0272,,42.48,31.86,31.86
WEBTPA EMPLOYER SERVICES - Medicare Part A,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,364.61,231.95,364.61,,,,,,SURGIFOAM ABS GELATIN SPONGE SZ 12-7,,0270,,22.3,16.725,16.725
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,141.8,20.71,250.4,,,,,,PADDING ABSORBENT,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1421.7,561.23,2500,,,,,,PORT MRI PLAS W/CATH 9.6FR,,0272,,821.18,615.885,615.885
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,"SUTURE, 4-0 VICRYL J662H",,0272,,6.19,4.6425,4.6425
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,36.74,5.81,65.1,,,,,,NEEDLE FILTER (BRAUN),,0270,,5,3.75,3.75
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,109.53,9.72,190.22,,,,,,SKIN MARKER WITH RULER,,0270,,5,3.75,3.75
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,59.76,5,105.9,,,,,,ESOPHAGUS/GASTROINTESTINAL TRACT,,0272,,107.64,80.73,80.73
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,79.68,9.87,141.2,,,,,,DRESSING HUMIFIBER 2X2 (ENLUXTRA),,0272,,25.33,18.9975,18.9975
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,DRESSING HUMIFIBER 4X4 (ENLUXTRA),,0272,,29.44,22.08,22.08
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,39.27,3.6,69.6,,,,,,CLAMP OSTOMY (HOLLISTER),,0270,,5,3.75,3.75
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,39.27,6.03,69.6,,,,,,PACK C-SECTION C.H(do not use),,0272,,49.83,37.3725,37.3725
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.38,6.15,4344.87,,,,,,CLAMP UMBILICAL CORD,,0270,,5,3.75,3.75
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,252.91,68.61,524.17,,,,,,STETHESCOPE DISPOSABLE YELLOW (HOPKINS),,0270,,6.31,4.7325,4.7325
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.48,12.56,48.28,,,,,,ANESTHESIA EPIDURAL IV SET,,0272,,19.27,14.4525,14.4525
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,530.12,62.92,1098.7,,,,,,ANESTHESIA EPIDURAL CASSETTE,,0272,,23.75,17.8125,17.8125
WEBTPA EMPLOYER SERVICES - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,130.46,95.05,222.03,,,,,,ANESTHESIA EPIDURAL EXT. SET,,0272,,13.41,10.0575,10.0575
WEBTPA EMPLOYER SERVICES - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,125.57,114.76,176.55,,,,,,"TRAY, THORACENTESIS (INTRODUCER NEEDLE)",,0272,,52.03,39.0225,39.0225
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,0,55,125,,,,,,BANDAGE HONEYCOMB 4 (MEDICHOICE),,0270,,5,3.75,3.75
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,13132,"Complex repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitalia, hands, and/or feet (2.6 to 7.5 cm) [HCPCS 13132]",615.02,461.27,461.27,0,55,55,,,,,,BANDAGE HONEYCOMB 6 (MEDICHOICE),,0270,,5,3.75,3.75
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,SUTURE 2-0 ETHIBOND EXCEL,,0272,,24.4,18.3,18.3
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,0,137.3,1347.57,,,,,,SUTURE 0 VICRYL VCP358H,,0272,,5.35,4.0125,4.0125
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,0,73.48,1221.85,,,,,,SUTURE 2-0 VICRYL VCP351H,,0272,,5.11,3.8325,3.8325
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,0,272.21,1200.54,,,,,,SUTURE 1 ETHIBOND EXCEL X425H,,0272,,5.53,4.1475,4.1475
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,0,166.13,1107.72,,,,,,SUTURE 0 ETHIBOND EXCEL X424H,,0272,,5.02,3.765,3.765
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,0,561.23,2500,,,,,,SUTURE 1 PROLENE 8435H,,0272,,7.24,5.43,5.43
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,0,8.87,355.2,,,,,,SUTURE VICRYL 5-0 VCP495G,,0272,,13.18,9.885,9.885
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,0,2.66,76.2,,,,,,BANDAGE STERI STRIPS 1/4x4,,0270,,5,3.75,3.75
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,0,5,105.9,,,,,,CONTAINER EVACUATION 1000ml,,0270,,24.72,18.54,18.54
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,0,6,88.2,,,,,,MAGNETIC INSTRUMENT PAD,,,,,,
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,0,3.6,69.6,,,,,,"SUTURE, 1-0 VICRYL J977H",,0272,,5.54,4.155,4.155
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,0,6.03,69.6,,,,,,"SUTURE, 1-0 VICRYL J947H",,0272,,5,3.75,3.75
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,45.23,37.79,110.3,,,,,,"SUTURE, 4-0 VICRYL VCP214H",,0272,,5.1,3.825,3.825
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,0,4.51,1156.79,,,,,,GEL COLLAGEN STIMULEN 1 0Z,,0270,,88.2,66.15,66.15
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,CATHETER URETHRAL 12FR (RED RUBBER),,0272,,11.53,8.6475,8.6475
"WELLCARE OF TEXAS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,0,62.92,1098.7,,,,,,BLOOD Y-TYPE SET,,0270,,14.36,10.77,10.77
AMBETTER - Commercial-HMO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,105.9,62.38,245.75,,,,,,ELECTRODE PEDIATRIC PACING (PHYSIO PAD,,0270,,44.07,33.0525,33.0525
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,16.71,2.44,580.94,,,,,,SUTURE 5-0 VICRYL PLUS ANTIBACT VCP433H,,0272,,6.9,5.175,5.175
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,199.19,20.71,250.4,,,,,,SUTURE 5-0 VICRYL PLUS ANTIBACT VCP303H,,0272,,5.05,3.7875,3.7875
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,178.99,90,225,,,,,,DERMABOND ADVANCE SKIN ADHESIVE,,0272,,44.45,33.3375,33.3375
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1997.1,561.23,2500,,,,,,LAMINARIA TENT (X-SMALL),,0272,,15.75,11.8125,11.8125
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,128.08,8.49,161,,,,,,LAMINARIA TENT (SMALL),,0272,,15.75,11.8125,11.8125
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,195.69,8.87,355.2,,,,,,DRESSING ACTICOAT,,0272,,32.41,24.3075,24.3075
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,236.82,14.4,297.7,,,,,,BOOT WALKING DIABETIC-MEDIUM,,0270,,202.78,152.085,152.085
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,68.41,9.42,73.71,,,,,,TRAY LACERATION E.R.,,0272,,14.8,11.1,11.1
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,60.62,2.66,76.2,,,,,,"SUTURE, 2-0 VICRYL J275H",,0272,,5,3.75,3.75
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,42.16,1.89,53,,,,,,DRESSING HUMIFIBER 6x6 (ENLUXTRA),,0272,,50.83,38.1225,38.1225
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,64.91,6.2,81.6,,,,,,SCALPEL SIZE 15 (MEDICHOICE),,0272,,5.06,3.795,3.795
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,76.37,5.44,96,,,,,,DRESSING OPTIFOAM NON-AD,,0272,,14.33,10.7475,10.7475
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,82530,Lab analysis to measure the amount of free cortisol (hormone) [HCPCS 82530],237.1,177.83,177.83,188.61,16.71,233.8,,,,,,BLADE SURGICAL SIZE 20,,0272,,5,3.75,3.75
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,154.41,9.72,190.22,,,,,,GEL MEDIHONEY,,0270,,13.56,10.17,10.17
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,84.24,5,105.9,,,,,,"SUTURE, 4-0 VICRYL J415H",,0272,,5,3.75,3.75
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,57.91,5.63,72.8,,,,,,"SUTURE, 3-0 VICRYL J864D",,0272,,24.56,18.42,18.42
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,107.95,14.11,134.34,,,,,,PACK LAP CHOLECYSTECTOMY CARDINAL,,0272,,58.72,44.04,44.04
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,112.32,9.87,141.2,,,,,,MULTI-LUMEN CVC KIT/PRESSURE INJECTABLE,,0272,,151.77,113.8275,113.8275
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,42.16,4.54,50.4,,,,,,UMBILICAL CLAMP CLIPPER (PURPLE),,0270,,5,3.75,3.75
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,70.16,6,88.2,,,,,,SUTURE 2-0 GUT LIGAPACK (L103G),,0272,,10.14,7.605,7.605
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,54.33,2.7,54.33,,,,,,TUBE-T 16FR,,0272,,28.32,21.24,21.24
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,112.32,9.2,112.32,,,,,,TUBE-T 14FR,,0272,,27.19,20.3925,20.3925
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,123.7,8.17,155.5,,,,,,PADS ELECTRODE (CHILD/INFANT),,0270,,157.56,118.17,118.17
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,131.58,45.82,378.9,,,,,,PADS ELECTRODE (ADULT),,0272,,79.56,59.67,59.67
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,83.53,29.48,105,,,,,,"KNEE IMMOBILIZER,LARGE (PM)",,0270,,32.59,24.4425,24.4425
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,97.45,6.15,4344.87,,,,,,"KNEE IMMOBILIZER,MEDIUM (PM)",,0270,,32.59,24.4425,24.4425
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,66.66,19.15,448.97,,,,,,NASOPHARYNGEAL AIRWAY 24FR (6.0MM),,0272,,10.65,7.9875,7.9875
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,355.27,28.6,1161.38,,,,,,NASOPHARYNGEAL AIRWAY 26FR (6.5MM),,0272,,10.75,8.0625,8.0625
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,77.24,16.26,2475.42,,,,,,NASOPHARYNGEAL AIRWAY 28FR (7.0MM),,0272,,12,9,9
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,355.27,68.61,524.17,,,,,,NASOPHARYNGEAL AIRWAY 30FR (7.5MM),,0272,,10.65,7.9875,7.9875
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,77.24,20.72,3197.1,,,,,,NASOPHARYNGEAL AIRWAY 32FR (8.0MM),,0272,,10.72,8.04,8.04
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,62.37,4.51,1156.79,,,,,,DRESSING SEASORB AG W/SILVER 6X6,,0272,,30.36,22.77,22.77
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,158.78,29.4,2785.69,,,,,,CONNECTOR STERILE 3/16,,0270,,5,3.75,3.75
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,31.58,12.56,48.28,,,,,,CATHETER 16FR. 5CC (BARD),,0272,,13.73,10.2975,10.2975
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,194.74,39.1,434.06,,,,,,COLLAR STIFNECK ADJUST (ADULT) OM,,0270,,14.48,10.86,10.86
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,306.19,61.48,2109.82,,,,,,"ADAPTOR, HUMIDIFIER (TRI-ANIM)",,0270,,6.03,4.5225,4.5225
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,453.51,50,3116.59,,,,,,PUNCH BIOPSY 2MM,,0272,,5,3.75,3.75
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,19.89,2.1,2819.66,,,,,,"SUTURE, 2-0 MONOCRYL (Y417H)",,0272,,6.09,4.5675,4.5675
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J1710,Hydrocortisone sodium ph inj [HCPCS J1710],13.43,10.07,10.07,10.69,10.69,10.69,,,,,,"SUTURE, 5MM MERSILENE (RS22)",,0272,,58.83,44.1225,44.1225
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,9.95,0.95,3583.7,,,,,,SUCTION TUBE FLEXIBLE (ARGYLE TIP),,0270,,5,3.75,3.75
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,11.03,1.72,16.28,,,,,,"CURETTE, EMDOMETRIAL SUCTION (PIPELLE)",,0272,,18.86,14.145,14.145
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,23.13,5.49,347.63,,,,,,CLIPS FILSHIE STERILE,,0278,,149.7,112.275,112.275
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,9.95,5.5,19.14,,,,,,"URETHRAL SUPPORT SYSTEM, (HOOK)",,0272,,"1,287",965.25,965.25
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,15.91,1.76,23.48,,,,,,"URETHRAL SUPPORT SYSTEM, (HOOK & HALO)",,0272,,"1,309.43",982.0725,982.0725
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,27.84,0.02,4433.9,,,,,,PESSARY FLEXIBLE GELLHORN 2 3/4,,0272,,96.72,72.54,72.54
AMBETTER - Commercial-HMO,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,3.98,2.4,4.25,,,,,,DETECTOR CO2 PEDIATRIC (AMBU),,0270,,22.27,16.7025,16.7025
WELLMARK BCBS OF IA MEDIGAP - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,139.54,39.1,434.06,,,,,,CYSTOSCOPY/IRRIGATION SET,,0272,,16.11,12.0825,12.0825
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,22.11,5.03,33.1,,,,,,PERINEAL WASH KIT (MEDLINE),,0270,,20.79,15.5925,15.5925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,19.16,19.16,56.63,,,,,,"SUTURE, MONOCRYL 2-0 (Y945H)",,0272,,6.81,5.1075,5.1075
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,28.79,18.04,43.1,,,,,,"SUTURE, CHROMIC GUT 1 (803H)",,0272,,10.36,7.77,7.77
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,28.79,18.04,43.1,,,,,,"SUTURE, PDS II 3-0 CR MONO",,0272,,41.5,31.125,31.125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,20.64,4.42,42.84,,,,,,ELECTRODE RESECTION LOOP 24FR,,0272,,206.39,154.7925,154.7925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,27.31,5.2,40.9,,,,,,FISCHER CONE BIOPSY EXCISOR (LG SHALLOW),,0272,,42.83,32.1225,32.1225
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,30.92,3.99,48.28,,,,,,PESSARY FLEXIBLE GELLHORN 2,,0270,,98.67,74.0025,74.0025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,20.64,5.07,94.54,,,,,,PESSARY FLEXIBLE GELLHORN 2-1/2,,0270,,96.72,72.54,72.54
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,22.11,13.86,33.1,,,,,,PESSARY FLEXIBLE GELLHORN 3,,0270,,98.67,74.0025,74.0025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,27.31,4.75,40.9,,,,,,PESSARY FLEXIBLE GELLHORN 3-1/2,,0270,,90.37,67.7775,67.7775
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,19.16,7.89,28.7,,,,,,PESSARY FLEXIBLE GELLHORN 3-1/4,,0270,,90.37,67.7775,67.7775
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,24.38,15.27,36.5,,,,,,PESSARY FLEXIBLE GELLHORN 2-1/4,,0270,,102.12,76.59,76.59
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,29.45,18.48,44.1,,,,,,KIT HIP 9,,0270,,44.8,33.6,33.6
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,22.11,4.35,39.58,,,,,,KNEE SEPARATOR,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,29.45,5.83,44.1,,,,,,COLLAR CERVICAL (UNIVERSAL),,0270,,10.36,7.77,7.77
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,21.44,4.02,32.1,,,,,,"CATHETER, WORD",,0272,,48.28,36.21,36.21
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,109.37,45.82,378.9,,,,,,SLEEVE SCD(THIGH)-MED (CARDINAL),,0270,,76.76,57.57,57.57
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,927.85,105.86,1389.2,,,,,,SLEEVE SCD-LG,,0270,,104.32,78.24,78.24
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,280.4,131.45,310.8,,,,,,"SUTURE, 0 VICRYL CT-1 J840D",,0272,,24.51,18.3825,18.3825
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,280.4,266.1,323.65,,,,,,"SUTURE, PLAIN GUT 4-0 (U207H)",,0272,,9.07,6.8025,6.8025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,280.4,35.11,337.46,,,,,,"SUTURE, VICRYL 5-0 (J391H)",,0272,,6.14,4.605,4.605
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,280.4,70.45,319.43,,,,,,SPONGE PEANUT (TELEFLEX),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,280.4,107.28,315.01,,,,,,CONTROL A FLO IV (DIALYSIS),,0272,,12.96,9.72,9.72
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,283.23,113,283.23,,,,,,"SUTURE, CHROMIC GUT 915H",,0272,,9.45,7.0875,7.0875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,G0438,"Ppps, initial visit [HCPCS G0438]",68.4,51.3,51.3,283.23,113,283.23,,,,,,BLOOD/FLUID WARMING I.V. SET,,0272,,24.47,18.3525,18.3525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,J0606,"Inj, etelcalcetide, 0.1 mg [HCPCS J0606]",6.84,5.13,5.13,4.57,4.57,4.57,,,,,,PACK C-SECTION FLUID COLLECTION IV,,0272,,81.24,60.93,60.93
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,9.31,6.13,13.93,,,,,,SEXUAL ASSAULT EVIDENCE KIT (5/CS),,0272,,41.3,30.975,30.975
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,1.67,1.1,3.07,,,,,,ADAPTOR MICRO SET SYRINGE,,0272,,19,14.25,14.25
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0.96,0.63,1.44,,,,,,PESSARY FLEXIBLE GELLHORN 1-3/4,,0272,,102.12,76.59,76.59
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Institutional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,6.07,4,9.09,,,,,,ANESTHESIA ADMIN SET,,0272,,19.27,14.4525,14.4525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,62.63,61.63,100.1,,,,,,SLEEVE SCD-SM (NEW),,0270,,61.01,45.7575,45.7575
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.07,2.07,19.9,,,,,,GVL 2 STAT LARYNGOSCOPE,,0272,,41.91,31.4325,31.4325
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,DIAPER ADULT BARIATRIC,,0270,,33.39,25.0425,25.0425
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,16.53,1.28,46.3,,,,,,"SUTURE, 5-0 PLAIN GUT 1915G",,0272,,15.92,11.94,11.94
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,0,36.98,63.97,,,,,,ANTI-FOG OUT SOLUTION ENDOSCOPIC,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,90750,Shingles vaccine for injection into muscle [HCPCS 90750],446.6,334.95,334.95,446.6,161.36,446.6,,,,,,PACK I.V. WARM MEDICHOICE,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.25,5.19,5.3,,,,,,TUBE REPLACEMENT STRAIGHT G-TUBE 20FR,,0272,,62.95,47.2125,47.2125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,22.45,8.98,23.86,,,,,,CYSTOSCOPY IRRIGATION SET (OM),,0272,,24.4,18.3,18.3
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,55.05,13.55,72.8,,,,,,"TUBE, TRACH 7MM (SMITH MEDICAL)",,0272,,44.8,33.6,33.6
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,88.65,62.38,245.75,,,,,,"TUBE, TRACH 6MM (SMITH MEDICAL)",,0272,,43.85,32.8875,32.8875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,125.38,70,166.6,,,,,,CANNULA INNER DISP (SMITHS MEDICAL),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,"TUBE, TRACH 8MM (SMITHS MEDICAL)",,0272,,43.99,32.9925,32.9925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Clinic,Professional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],26.3,19.73,19.73,2.55,1.31,26.3,,,,,,CANOPY OHIO PEDIATRIC AEROSOL,,0270,,34.55,25.9125,25.9125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,350.31,214.38,2255.8,,,,,,MESH PERFIX PLUG LARGE,,0278,,260.78,195.585,195.585
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Dialysis Clinic,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,288.11,242.91,1540,,,,,,ELECTRODE VAPORIZATION (VAPORTRODE),,0272,,838.28,628.71,628.71
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,899.92,393.52,2894.06,,,,,,TED HOSE-THIGH X-LG REGULAR,,0270,,14.53,10.8975,10.8975
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,11043,Skin and muscle removal (first 20 sq cm or less) [HCPCS 11043],2098.2,1573.65,1573.65,1391.28,837.32,1391.28,,,,,,CUTTER ENDO LINEAR FLEX 45,,0272,,414.95,311.2125,311.2125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,11045,Skin and tissue removal (each additional 20 sq cm) [HCPCS 11045],132.3,99.23,99.23,87.48,52.8,87.48,,,,,,HOLLISTER 4X4 HYDROFERA BLUE,,0272,,18.38,13.785,13.785
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,11046,Skin and muscle removal (each additional 20 sq cm) [HCPCS 11046],282.3,211.73,211.73,188.55,112.64,188.55,,,,,,BARD CATHETER 10FR-3CC,,0272,,11.94,8.955,8.955
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,83.49,55,125,,,,,,ENDOSCOPIC MULTIPLE CLIP APPLIER,,0272,,213.06,159.795,159.795
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,17250,Chemical agent application to wound tissue [HCPCS 17250],709,531.75,531.75,468.8,205.89,468.8,,,,,,"TUBING, CONNECTING (MEDICHOICE)DARK BLUE",,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,13.89,2.44,580.94,,,,,,RELOAD ENDOCUTTER 45MM 6R45B (J&J),,0272,,185.44,139.08,139.08
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,780.04,494.34,1384.62,,,,,,EXT SET IV MINI VOL (SURGERY),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,36600,Collection of blood specimen from arterial puncture for diagnosis [HCPCS 36600],293.6,220.2,220.2,0,39.78,171.67,,,,,,CANNULA NEONATE 7' STAR TUBE,,0270,,11.78,8.835,8.835
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,47564,Gallbladder removal with inspection of common bile duct with endoscope [HCPCS 47564],23177.61,17383.21,17383.21,3524.91,3524.91,3524.91,,,,,,BLANKET UPPER BODY (STRYKER),,0270,,14.08,10.56,10.56
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,49083,Abdominal cavity fluid drainage with imaging guidance [HCPCS 49083],403,302.25,302.25,74.39,74.39,125,,,,,,BLANKET LOWER BODY (STRYKER),,0270,,16.96,12.72,12.72
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,198.83,119.94,617.26,,,,,,BLANKET FULL BODY (STRYKER),,0270,,14.11,10.5825,10.5825
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70140,Facial bones x-ray for injuries or lesions (less than 3 views) [HCPCS 70140],225,168.75,168.75,148.78,123.34,148.78,,,,,,BAG DRAPE-STERI ISOLATION,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70260,"Skull bones x-ray (complete study, minimum of 4 views) [HCPCS 70260]",377.1,282.83,282.83,251.86,251.86,251.86,,,,,,NYLON THIGH MEDIUM STOCKING,,0270,,14.93,11.1975,11.1975
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,1039.57,137.3,1347.57,,,,,,SEALERS TISSUE TRIO ENSEAL,,0272,,576.82,432.615,432.615
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,664.85,73.48,1221.85,,,,,,MESH PERFIX PLUG MEDIUM (DAVOL),,0278,,257.66,193.245,193.245
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70496,CTA scan of head blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70496],1345.1,1008.83,1008.83,889.41,563.64,889.41,,,,,,MESH PERFIX PLUG X-LARGE,,0278,,267.81,200.8575,200.8575
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70498,CTA scan of neck blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70498],1345.1,1008.83,1008.83,889.41,294.63,889.41,,,,,,MESH PRE-SHAPED WITH KEYHOLE,,0278,,99.11,74.3325,74.3325
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70549,"Imaging of neck blood vessels by MRA without contrast, followed by contrast [HCPCS 70549]",1974.7,1481.03,1481.03,1308.35,1308.35,1308.35,,,,,,STAPLER ENDOPATH 60MM ARTICULATION (J&J),,0272,,438.02,328.515,328.515
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",1974.7,1481.03,1481.03,1308.35,561.23,1308.35,,,,,,RELOAD 60MM GRAY(MESENTERY/THIN) (J&J),,0272,,217.4,163.05,163.05
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,165.57,20.71,250.4,,,,,,RELOAD 60MM ECHILON 60MM,,0272,,217.4,163.05,163.05
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,179.39,28.74,271.3,,,,,,RELOAD 60MM GOLD (REGULAR/THICK) (J&J),,0272,,217.4,163.05,163.05
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,148.78,94.25,177.23,,,,,,RELOAD 60MM GREEN (THICK) (J&J),,0272,,217.4,163.05,163.05
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,874.8,137.3,1124.55,,,,,,RELOAD PROXIMATE LINEAR CUTTER 75MM,,0272,,137.32,102.99,102.99
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,933.91,272.21,1200.54,,,,,,LINEAR CUTTER 75MM (NTLC75),,0272,,91.67,68.7525,68.7525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1412.4,1059.3,1059.3,898.39,272.21,898.39,,,,,,STAPLER ENDO 25MM CURVED,,0272,,410.64,307.98,307.98
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,148.78,4.45,148.78,,,,,,STAPLER ENDO 29MM CURVED,,0272,,410.64,307.98,307.98
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72050,Spinal x-ray of upper spine (4 or 5 views) [HCPCS 72050],355,266.25,266.25,234.73,50.72,234.73,,,,,,"TROCAR HUBLESS, 19FR ROUND",,0272,,107.52,80.64,80.64
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],246,184.5,184.5,162.99,107.22,162.99,,,,,,STRAP ABSORBABLE SECURESTRAP,,0272,,680.95,510.7125,510.7125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,149.08,69.84,223.7,,,,,,LOOP VESSEL,,0272,,6.92,5.19,5.19
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,150.28,4.41,166.13,,,,,,SUTURE 4-0 MONOCRYL (Y845G),,0272,,13.63,10.2225,10.2225
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,863.21,166.13,1107.72,,,,,,SUTURE 1-0 PDS II CTX MONO (Z371T),,0272,,7.86,5.895,5.895
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,883.64,166.13,1309.77,,,,,,SUTURE 3-0 CTD VICRYL (J110T),,0272,,18.69,14.0175,14.0175
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,693.4,350.85,825.61,,,,,,SUTURE 2-0 CTD VICRYL (J607H),,0272,,5.16,3.87,3.87
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72191,"CTA scan of pelvic blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 72191]",1345.1,1008.83,1008.83,898.39,898.39,898.39,,,,,,SUTURE 2-0 CTD VICRYL (J911T),,0272,,17.34,13.005,13.005
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,72220,X-ray of sacrum and tailbone (minimum of 2 views) [HCPCS 72220],225,168.75,168.75,148.93,94.25,148.93,,,,,,SUTURE 0 CTD VICRYL (J608H),,0272,,5.26,3.945,3.945
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,148.78,94.25,222.4,,,,,,SUTURE 0 CTD VICRYL (J912G),,0272,,17.68,13.26,13.26
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],225,168.75,168.75,148.78,27.4,191.25,,,,,,MARKER ENDOSCOPIC (SPOT),,0272,,69.54,52.155,52.155
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,148.78,25.73,191.25,,,,,,FORCEPS RJ 4 JUMBO 240CM,,0272,,71.13,53.3475,53.3475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",225,168.75,168.75,148.78,94.25,180,,,,,,BIOPSY HOT RADIAL JAW 240CM,,0272,,64.46,48.345,48.345
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,148.78,24.39,148.78,,,,,,SNARE SENSATION (FLEXIBLE) 27MM,,0272,,24.95,18.7125,18.7125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,148.78,18.85,148.78,,,,,,SNARE ROTATABLE (MED STIFF) 20MM,,0272,,44.17,33.1275,33.1275
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,149.08,99,166.13,,,,,,TWISTER POLYP RETRIEVAL NET 26MM,,0272,,112.33,84.2475,84.2475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,148.78,57.76,225,,,,,,INTERJECT CLEAR 7F 25G 4MM 240CM,,0272,,89.09,66.8175,66.8175
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],225,168.75,168.75,148.78,35.41,222.75,,,,,,RESOLUTION 360 CLIP 235CM,,0272,,284.7,213.525,213.525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,148.78,29.4,177.53,,,,,,NEEDLE SET PLUS EZ-IO 45MM (BARIATRIC),,0272,,222.46,166.845,166.845
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,148.78,94.25,214.2,,,,,,NEEDLE SET PLUS EZ-IO 25MM (ADULT),,0272,,222.46,166.845,166.845
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,148.78,94.25,191.25,,,,,,NEEDLE SET PLUS EZ-IO 15MM (PEDI),,0272,,218.48,163.86,163.86
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,148.78,69.84,225,,,,,,CIRCUIT VENTILATOR (ZOLL),,0272,,35.28,26.46,26.46
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,148.78,37.7,213.75,,,,,,SUCTION CATH. 8FR GRADUATED,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],225,168.75,168.75,148.78,94.25,148.78,,,,,,MOUTHPIECE ENDOSCOPE SUB,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",694.6,520.95,520.95,459.28,166.13,526.22,,,,,,IRRIGATION SYRINGE 60CC,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,73718,Imaging of leg by MRI without contrast [HCPCS 73718],1046.4,784.8,784.8,691.9,691.9,691.9,,,,,,"SHOE, ADULT HEEL WALKING CAST",,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,150.28,90,225,,,,,,BURST POUCH WITH ORA-SWAB SUCTION,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,150.28,31.41,166.13,,,,,,SUCTION CATHETER TRAY14FR WITH VALVE,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,74150,"Abdominal CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74150]",1267.9,950.93,950.93,846.83,166.13,1077.72,,,,,,CATHETER DRAINAGE 2 EYES (12FR),,0272,,19.47,14.6025,14.6025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,74175,Abdominal blood vessels CTA scan with contrast [HCPCS 74175],1345.1,1008.83,1008.83,898.39,898.39,898.39,,,,,,CATHETER DRAINAGE 2 EYES (14FR),,0272,,19.47,14.6025,14.6025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1662.74,180.22,3324.06,,,,,,CATHETER JEJUNOSTOMY (16FR),,0272,,459.04,344.28,344.28
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1676.76,561.23,2500,,,,,,SUTURE 4-0 PDS PLUS,,0272,,8.27,6.2025,6.2025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,74300,X-ray of bile and/or pancreatic ducts during surgery including radiological supervision of procedure and interpretation of results [HCPCS 74300],88.2,66.15,66.15,58.91,58.91,58.91,,,,,,SUTURE 2-0 CHROMIC 816H (J&J),,0272,,9.28,6.96,6.96
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,495.26,110.94,589.78,,,,,,HEAD POSITIONER (ANES),,0270,,14.96,11.22,11.22
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,214.07,62.12,274.64,,,,,,CUTTER ENDO LINEAR FLEX 45 (J&J ORTHO),,0272,,393.32,294.99,294.99
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,432.37,166.13,529.3,,,,,,FISCHER CONE BIOPSY EXCISOR (LARGE),,0272,,43.91,32.9325,32.9325
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,313.05,137.3,401.67,,,,,,CATHETER POWERPORT MRI 8FR,,0272,,668.79,501.5925,501.5925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,436.74,107.93,965.26,,,,,,STOPCOCK 3 WAY HBE,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,448.5,166.13,529.81,,,,,,CATHETER FOLEY 6FR 1.5CC PEDIATRIC,,0272,,45.05,33.7875,33.7875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,371.14,166.13,1065.48,,,,,,TIP PYRAMIDAL CANNULA/TROCAR HUNT APPLE,,0272,,84.24,63.18,63.18
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",468.7,351.53,351.53,311.42,166.13,311.42,,,,,,PORT SIDE CANNULA/TROCAR HUNT APPLE,,0272,,99.18,74.385,74.385
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76870,Imaging of scrotum by ultrasound [HCPCS 76870],468.7,351.53,351.53,309.92,166.13,309.92,,,,,,CATHETER TROCAR 8FR,,0272,,43.66,32.745,32.745
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],309.9,232.43,232.43,204.92,22.66,204.92,,,,,,CATHETER TROCAR 10FR,,0272,,43.66,32.745,32.745
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,88.93,23.61,157.86,,,,,,SUTURE 3-0 VICRYL J416H (UNDYED),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,322.66,108.36,412.85,,,,,,SUTURE 0 VICRYL J946H (UNDYED),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,196.84,89.59,349.41,,,,,,PATCH BIO-PATCH DISK WITH CHG,,0272,,23.06,17.295,17.295
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,106.46,8.49,161,,,,,,KIT CENTRAL LINE,,0272,,24.28,18.21,18.21
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,0,41.68,551.29,,,,,,SUCTION CANISTER 1500ML,,0272,,7.78,5.835,5.835
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,162.66,8.87,355.2,,,,,,PERINEAL SENSICARE CLEANSER 8OZ,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,98.46,11.25,148.9,,,,,,SPONGE 4X4 8 PLY,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,308.57,48.41,364.52,,,,,,SPONGE COVER 4X4 (POST-OP SPONGE),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,122.52,8.3,183.45,,,,,,CIRCUIT VENTILATOR,,0272,,8.01,6.0075,6.0075
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],99.3,74.48,74.48,13.12,13.12,94.5,,,,,,DRESSING STERILE COBAN 3,,0272,,7.24,5.43,5.43
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80197,Lab analysis to measure the amount of tacrolimus in blood specimen [HCPCS 80197],389.3,291.98,291.98,257.41,163.11,257.41,,,,,,STAPLER SKIN ROTATING HEAD (REG),,0272,,41.3,30.975,30.975
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,198.84,14.4,297.7,,,,,,DRESSING SILVERCEL 4.25X4.25IN,,0272,,20.32,15.24,15.24
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,518.42,63.16,518.42,,,,,,LOOP VESSEL (RED) OM,,0272,,34.55,25.9125,25.9125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,56.87,9.42,73.71,,,,,,DERMA GRAN WOUND CLEANSER (OM),,0270,,8.43,6.3225,6.3225
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,50.39,2.66,76.2,,,,,,CURITY SPONGE 4X4 12 PLY,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,35.05,1.89,53,,,,,,PRIMARY CONT-FLO I/V (NON-DEHP),,0272,,10.75,8.0625,8.0625
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82010,"Lab analysis to measure the amount of ketone bodies in blood, serum, or plasma specimen [HCPCS 82010]",75.6,56.7,56.7,0,8.3,45.2,,,,,,SECONDARY (NON-DEHP),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,17.7,2.31,20.91,,,,,,STERILE 5 SPONGE 4X4 12 PLY (SUB),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82103,Lab analysis to identify total alpha-1-antitrypsin (protein) in blood specimen [HCPCS 82103],124.7,93.53,93.53,82.46,82.46,82.46,,,,,,DRESSING 4X5 TELFA ISLAND,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],314.3,235.73,235.73,91.91,14.09,91.91,,,,,,DRESSING 4X14 TELFA ISLAND,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82108,Lab analysis to measure the the aluminum level in blood specimen [HCPCS 82108],118,88.5,88.5,25.48,25.48,25.48,,,,,,SIGMOID SUCTION 6,,0272,,7.37,5.5275,5.5275
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],137.9,103.43,103.43,91.18,14.81,137.9,,,,,,SCISSORS 5MM CURVED,,0272,,85.54,64.155,64.155
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,63.47,5.44,96,,,,,,SUTURE 0 PROLENE CT-1 (BLUE),,0272,,6.75,5.0625,5.0625
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,191.82,30.08,290.1,,,,,,SUTURE 2-0 PROLENE CT-1 (BLUE),,0272,,7.65,5.7375,5.7375
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,43.05,5.81,65.1,,,,,,ENEMA GREEN SALINE PHOSPHATE (SUB),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,65.66,11.55,98.31,,,,,,LINE SAMPLING ADULT,,0270,,18.88,14.16,14.16
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,64.2,4.35,81.23,,,,,,"SUTURE, 3-0 PLAIN GUT (842H) (J&J)",,0272,,8.21,6.1575,6.1575
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,82.46,12.67,98.39,,,,,,WIRE GUIDE HYDROPHILIC (320CM),,0272,,90.39,67.7925,67.7925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,307.66,32.34,465.3,,,,,,SYRINGE CONTROL 10ML,,0272,,12,9,9
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,78.09,11.45,112.4,,,,,,SUTURE BOOT STANDARD (YELLOW IN BLUE),,0272,,7.49,5.6175,5.6175
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,161.13,14.94,192.28,,,,,,FORCEPS ALLIGATOR GRASPING LONG,,0272,,117,87.75,87.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82803,Lab analysis to measure the amount of blood gases [HCPCS 82803],293.3,219.98,219.98,0,26.5,223.7,,,,,,NEEDLE BIOPSY ACQUIRE EUS 19G,,0272,,715,536.25,536.25
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,6.15,2.66,8.7,,,,,,CRICOTHYPOTOMY SET 6MM,,0270,,228.17,171.1275,171.1275
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,82977,Lab analysis to measure the glutamyltransferase (liver enzyme) level [HCPCS 82977],65.1,48.83,48.83,43.05,11.93,52.08,,,,,,CRICOTHYPOTOMY SET 3.5MM,,0270,,227.84,170.88,170.88
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,76.64,8.16,104.31,,,,,,BALLOON GUIDED PRO WIRE CRE,,0272,,277.51,208.1325,208.1325
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,299.66,11.58,453.2,,,,,,DRAIN PENROSE 3/4 X 18 (CR BARD),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83519,Lab analysis to measure the amount of substance by radioimmunoassay [HCPCS 83519],931.7,698.78,698.78,18.4,15.46,100.28,,,,,,DRAIN PENROSE 3/4 X 12 (CR BARD),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,33.59,5.43,33.59,,,,,,TROCAR 5x100MM Kii FIOS ADVFIX,,0272,,140.4,105.3,105.3
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,38.68,7.34,38.68,,,,,,KIT COLONOSCOPY (ENDOKIT),,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,128.34,9.72,190.22,,,,,,KIT EGD (ENDOKIT),,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,20.64,5.07,94.54,,,,,,FORCEPS RADIAL JAW LG 2.8MM,,0272,,43,32.25,32.25
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,70.02,5,105.9,,,,,,BEIGE GOLD TEX KINESIO,,0270,,87.69,65.7675,65.7675
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,48.13,5.63,72.8,,,,,,CARTER-THOMASON CLOSURE SYSTEM,,0272,,210.6,157.95,157.95
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,186.66,32.98,268.8,,,,,,GUIDE PILOT 15MM,,0272,,51.4,38.55,38.55
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,89.4,41.96,133.85,,,,,,MESH HERNIA REP. DEVICE (ZENAPRO) 20X30,,0278,,"7,150",5362.5,5362.5
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,27.31,4.75,40.9,,,,,,SUTURE PASSER REVERDIN NOVAPASS,,0272,,266.5,199.875,199.875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84134,Lab analysis to measure the prealbumin (protein) level in urine specimen [HCPCS 84134],239.3,179.48,179.48,158.23,24.19,158.23,,,,,,SUTURE 4-0 PLAIN GUT G321H,,0272,,8.36,6.27,6.27
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84145,Lab analysis to measure the procalcitonin (hormone) level in serum or plasma specimen [HCPCS 84145],398.1,298.58,298.58,265.89,27.66,265.89,,,,,,GRAFT HERNIA 20X30 (BIODESIGN),,0278,,"15,398.5",11548.875,11548.875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,210.65,18.45,315.4,,,,,,MASK NRB PEDI HUDSON,,0270,,6.05,4.5375,4.5375
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,24.38,15.27,36.5,,,,,,CANNULA NASAL (INFANT),,0272,,9.39,7.0425,7.0425
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,38.68,3.73,46.16,,,,,,MERSILINE 5mm M0-4 NEEDLE,,0272,,56.67,42.5025,42.5025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84165,Lab analysis to measure the amount of protein in serum specimen [HCPCS 84165],186.4,139.8,139.8,124.5,78.1,124.5,,,,,,SUTURE 0 PDS PLUS CT-2 PDP334H,,0272,,8.51,6.3825,6.3825
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84166,Lab analysis to measure the amount of protein in body fluid specimen [HCPCS 84166],233.8,175.35,175.35,17.83,17.83,229.12,,,,,,CIRCUIT PASSIVE ADULT,,0272,,41.27,30.9525,30.9525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,86.03,7.58,134.6,,,,,,MASK CAPSTRAP (SMALL),,0270,,46.33,34.7475,34.7475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,89.73,14.11,134.34,,,,,,MASK CAPSTRAP (LG),,0270,,46.33,34.7475,34.7475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,102.82,14.41,153.94,,,,,,FILTER BACTERIA,,0270,,8.74,6.555,6.555
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",233.8,175.35,175.35,154.59,17.22,200.91,,,,,,ADAPTOR TRACH FLEX VENT,,0272,,11.63,8.7225,8.7225
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,93.37,9.87,141.2,,,,,,STETHOSCOPE ESOPHAGEAL 18FR,,0270,,6.09,4.5675,4.5675
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,35.05,4.54,50.4,,,,,,MASK CAPSTRAP (MED),,0270,,46.33,34.7475,34.7475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,129.07,17.05,191.3,,,,,,SET BILE DUCT EXPLORATION,,0272,,"1,164.8",873.6,873.6
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],44.1,33.08,33.08,6.68,2.41,10,,,,,,SUTURE 3-0 VICRYL J232H (UNDYED),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],12.2,9.15,9.15,6.68,2.41,10,,,,,,SUTURE 2-0 VICRYL J269H (UNDYED),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,58.32,6,88.2,,,,,,TUBE TRACHEAL BOUGIE 15FR,,0272,,15.46,11.595,11.595
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,25.05,5.43,37.5,,,,,,DRESSING PROMOGRAN MATRIX(4.34SQ)HEXAGON,,0272,,21.68,16.26,16.26
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,126.89,8.55,182.7,,,,,,CATHETER SET RADIAL ARTERY,,0272,,22.58,16.935,16.935
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,46.03,3.6,69.6,,,,,,CURETTE DERMAL 4MM DISPOSABLE,,0270,,5.93,4.4475,4.4475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,45.15,2.7,54.33,,,,,,CURETTE DERMAL DISPOSABLE 7MM,,0270,,5.93,4.4475,4.4475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,46.03,6.03,69.6,,,,,,NASOPHARYNGEAL AIRWAY 34FR 8.5MM,,0272,,10.7,8.025,8.025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,174.3,12.29,258.33,,,,,,NASOPHARYNGEAL AIRWAY 36FR (9.0MM),,0272,,14.58,10.935,10.935
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,50.39,5.26,76.2,,,,,,ADAPTOR HUMIDIFIER 040 (OM),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,96.28,12.2,112.96,,,,,,INSULFFLATOR TUBE SET HEATED HIGH FLOW,,0272,,81.23,60.9225,60.9225
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,149.5,18.22,199.4,,,,,,SUTURE 3-0 PROLENE 8832H,,0272,,9.93,7.4475,7.4475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,154.59,12.25,187.04,,,,,,SPONGE 4X4 12 PLY (MEDLINE),,0270,,5.38,4.035,4.035
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86304,"Lab analysis to identify tumor antigens by immunoassay (quantitative, CA 125) [HCPCS 86304]",311,233.25,233.25,207.71,130.28,207.71,,,,,,BLADE MAC SIZE 3,,0272,,14.96,11.22,11.22
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86335,Lab analysis by immunologic analysis technique on body fluid (other fluids with concentration) [HCPCS 86335],155.5,116.63,116.63,102.82,29.83,102.82,,,,,,BLADE MAC SIZE 4,,0272,,14.96,11.22,11.22
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,81.01,14.79,121.3,,,,,,EPIDURAL CATHERIZATION KIT (ARROW),,0272,,48.65,36.4875,36.4875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,123.25,5.76,186.4,,,,,,SUTURE 4-0 MONOCRYL (Y426H),,0272,,13.92,10.44,10.44
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],421.2,315.9,315.9,278.51,176.48,278.51,,,,,,KIT ARTERIAL LINE (ARROW),,0272,,83.27,62.4525,62.4525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,40.87,4.34,61.8,,,,,,BLADE MILLER SIZE 2,,0272,,14.96,11.22,11.22
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,51.84,6.74,92.02,,,,,,BLADE MILLER SIZE 3,,0272,,14.96,11.22,11.22
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,40.87,2.99,62.24,,,,,,SYRINGE BULB IRRIGATION 60CC,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,32.14,2.99,48.11,,,,,,VENI LOOP I/V (SUB),,0272,,5.61,4.2075,4.2075
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,82.49,11.93,144.95,,,,,,CLIPS FOAM NOSE,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,93.37,9.2,112.32,,,,,,MASK OXYGEN/SIMPLE (PEDI),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],54.4,40.8,40.8,0,9.6,22.79,,,,,,CHLORAPREP 26ML (ORANGE TINT),,0270,,24.04,18.03,18.03
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87046,Lab analysis of stool culture to identify bacteria and additional pathogens [HCPCS 87046],54.4,40.8,40.8,9.44,7.93,15.66,,,,,,STOMAHESIVE POWDER,,0272,,9.54,7.155,7.155
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,8.53,7.24,496.86,,,,,,BAG DECANTER,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,9.38,9.38,86.39,,,,,,SUTURE 3-0 SILK C017D,,0272,,22.94,17.205,17.205
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,66.39,6.79,100.4,,,,,,PROBE SURGICAL COVER,,0270,,16.35,12.2625,12.2625
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,71.48,2.84,108.1,,,,,,CATHETER ELECTROHEMOSTASIS (GOLD PROBE),,0272,,328.43,246.3225,246.3225
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,16.39,6.8,52.43,,,,,,CURETTE DERMAL 5MM DISPOSABLE,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],56.8,42.6,42.6,8.9,8.9,23.8,,,,,,CURETTE DERMAL 3MM DISPOSABLE,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,114.88,7.27,172,,,,,,SKIN BARRIER STOMAHESIVE 5x5 57mm,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],56.8,42.6,42.6,17.98,12.41,29.8,,,,,,POUCH SURFIT DRAIN 12 2 1/4,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87328,Lab analysis by immunoassay (ELISA) to identify cryptosporidium (parasite) [HCPCS 87328],136.8,102.6,102.6,13.82,11.61,22.91,,,,,,TURBINE DISPOSABLE (FLOWMIR),,0270,,6.06,4.545,4.545
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,102.82,8.17,155.5,,,,,,SENSOR FLOW DISPOSABLE (SUB),,0272,,13.74,10.305,10.305
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,73.67,37.79,110.3,,,,,,GRAFT HERNIA 10X10 (BIODESIGN),,0278,,"2,814.5",2110.875,2110.875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],211.7,158.78,158.78,0,11.89,22.79,,,,,,VENI LOOP I/V ( SUB 2),,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",342.7,257.03,257.03,0,11.91,22.84,,,,,,"SUTURE, 4-0 PROLENE SH SINGLE ARM",,0272,,9.43,7.0725,7.0725
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,35.09,29.48,155.5,,,,,,"SUTURE, 4-0 PROLENE RB-1 DOUBLE ARM",,0272,,13.55,10.1625,10.1625
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],282.3,211.73,211.73,37.27,31.31,118.27,,,,,,SWAB BENZOIN (MEDLINE),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87497,Lab analysis by nucleic acid (DNA or RNA) to measure the amount of cytomegalovirus [HCPCS 87497],466.5,349.88,349.88,311.58,195.45,311.58,,,,,,CLOTH CHLORHEXIDINE 2%,,0272,,8.07,6.0525,6.0525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87522,Lab analysis to measure the amount of Hepatitis C virus [HCPCS 87522],325.3,243.98,243.98,0,143.13,322.55,,,,,,BRUSHES FISTULA,,0270,,100.15,75.1125,75.1125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,35.09,29.48,155.5,,,,,,CANOPY OHIO PEDI AEROSOL (OWENS),,0270,,39.82,29.865,29.865
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,109.37,45.82,378.9,,,,,,KINESIO TEX GOLD TAPE,,0270,,31.29,23.4675,23.4675
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,69.43,29.48,105,,,,,,CAPSURE PERMANENT FIXATION SYSTEM (15),,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,87798,Lab analysis by nucleic acid (DNA or RNA) to identify organism by amplified probe technique [HCPCS 87798],638.4,478.8,478.8,426.39,267.52,426.39,,,,,,NEEDLE 1/2 CIRCLE ALLEN RICHARD,,0272,,14.44,10.83,10.83
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,88108,Lab examination of specimen by the conentration technique to diagnose disease [HCPCS 88108],33.1,24.83,24.83,21.89,13.86,38.85,,,,,,CATHETER 5CC TRAY INSERTION,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,22.11,13.86,24.19,,,,,,SLEEVE SCD MEDIUM LENGTH KNEE,,0270,,36.64,27.48,27.48
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,22.11,20.12,77.89,,,,,,SLEEVE SCD LARGE KNEE LENGTH,,0270,,89.11,66.8325,66.8325
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,89055,Lab analysis to measure the amount of white blood cells in stool specimen [HCPCS 89055],65.1,48.83,48.83,4.27,3.59,27.28,,,,,,"TAPE, MEDIPORE 4X10",,0270,,20.36,15.27,15.27
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,80.99,6.15,4344.87,,,,,,MASK AEROSOL ADULT HI-CONCENT (SUB),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,311.42,39.27,311.42,,,,,,DRESSING EXU DRY 6X9,,0272,,8.89,6.6675,6.6675
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],713.4,535.05,535.05,471.72,307.94,471.72,,,,,,CATHETER EXT MALE MEDIUM,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,93925,Leg ultrasound of arteries and arterial grafts of both legs (complete study) [HCPCS 93925],1018.8,764.1,764.1,673.66,350.85,673.66,,,,,,NEBULIZER PREFILLED FIO2 500ML,,0270,,17.03,12.7725,12.7725
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,93926,Arteries and arterial grafts ultrasound of one leg (limited study) [HCPCS 93926],713.4,535.05,535.05,471.72,166.13,606.39,,,,,,NASOPHARYNGEAL AIRWAY 34FR (9.0MM),,0272,,10.65,7.9875,7.9875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",1427.8,1070.85,1070.85,944.09,350.85,944.09,,,,,,SUTURE MONOCRYL 4-0 Y426H (OWENS),,0272,,13.92,10.44,10.44
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,476.48,166.13,1092.27,,,,,,SHEET BURN STERILE (OWENS),,0272,,15.45,11.5875,11.5875
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,55.97,19.15,448.97,,,,,,"SUTURE, 4-0 ETHILON 1854G",,0272,,12.45,9.3375,9.3375
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,295.31,28.6,1161.38,,,,,,ENDOSCOPIC BLUNT TIP DISSECTORS,,0272,,31.74,23.805,23.805
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,51.05,16.26,2475.42,,,,,,ENDO-POUCH (J&J),,0272,,91.5,68.625,68.625
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,298.29,68.61,524.17,,,,,,NEEDLE TENSION PNEUMOTHORAX 14G,,0272,,34.62,25.965,25.965
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,51.56,20.72,3197.1,,,,,,RELOAD ENDOCUTTER WHITE ECR45W (J&J),,0272,,199.22,149.415,149.415
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,61.91,34.19,143.78,,,,,,RELOAD ENDOCUTTER BLUE ECR45B (J&J),,0272,,199.22,149.415,149.415
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,51.84,4.51,1156.79,,,,,,RELOAD ENDOCUTTER GOLD ECR45D (J&J),,0272,,199.22,149.415,149.415
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,131.98,29.4,2785.69,,,,,,RELOAD ENDOCUTTER GREEN ECR45G (J&J),,0272,,199.22,149.415,149.415
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,25.05,12.56,48.28,,,,,,LAMINARIA TENT (MEDIUM),,0272,,13.13,9.8475,9.8475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,25.05,10.24,44.01,,,,,,TRAY SUPRAPUBIC,,0272,,83.76,62.82,62.82
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,74.39,40.84,136.8,,,,,,PATCH HERNIA VENTRALEX (SMALL CIRCLE),,0278,,564.07,423.0525,423.0525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,81.82,40.84,143.78,,,,,,PATCH HERNIA VENTRALEX (MED CIRCLE),,0278,,675.38,506.535,506.535
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],101.5,76.13,76.13,67.11,37.78,80.08,,,,,,PATCH HERNIA VENTRALEX (LG CIRCLE),,0278,,849.41,637.0575,637.0575
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,55.41,23.51,98.36,,,,,,SPECIPAN (MEDEGEN),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,241.35,140.59,428.4,,,,,,TRAP POLYP 4 CHAMBER (CATCHEM),,0272,,18.67,14.0025,14.0025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,241.75,140.59,241.75,,,,,,SUTURE PDS II 2-0 CT-1 MONO,,0272,,7.27,5.4525,5.4525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,87.7,40.84,154.11,,,,,,SUTURE PDS II 2-0 CT-2,,0272,,7.87,5.9025,5.9025
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,97597,Tissue removal from wounds per session (first 20 sq cm or less) [HCPCS 97597],709,531.75,531.75,468.8,85.58,468.8,,,,,,SIGMOIDOSCOPE DISPOSABLE,,0272,,17.56,13.17,13.17
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99195,Whole blood removal by needle to correct blood level imbalance [HCPCS 99195],175.4,131.55,131.55,115.98,73.48,115.98,,,,,,CANNULA INNER DISPOSABLE 6DIC,,0272,,10.62,7.965,7.965
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,280.4,35.11,337.46,,,,,,BLADE #3 CHANNELED VISION KING,,0272,,46.59,34.9425,34.9425
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,280.4,70.45,319.43,,,,,,SUTURE CHROMIC GUT 1 48G,,0272,,24.05,18.0375,18.0375
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,87.7,2.2,117.5,,,,,,STENT DOUBLE PIGTAIL URETERAL,,0272,,201.77,151.3275,151.3275
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,163.5,39.1,434.06,,,,,,STRAIGHT TIP GLIDEWIRE 0.038 DIA,,0272,,86.01,64.5075,64.5075
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,254.5,61.48,2109.82,,,,,,RELOAD 30MM WHITE (VASCULAR) (J&J),,0272,,80.89,60.6675,60.6675
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,376.96,50,3116.59,,,,,,RELOAD 30MM BLUE (REGULAR) (J&J),,0272,,78.68,59.01,59.01
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,618.97,62.92,1098.7,,,,,,RELOAD STAPLER LINEAR 60MM,,0272,,84.74,63.555,63.555
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,98.4,2.42,250.2,,,,,,RELOAD 30MM GREEN (THICK) (J&J),,0272,,78.68,59.01,59.01
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,G0328,Fecal blood scrn immunoassay [HCPCS G0328],48.8,36.6,36.6,32.59,20.42,48.31,,,,,,RELOAD PROXIMATE LINEAR STAP,,0270,,84.74,63.555,63.555
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,16.23,5.83,3301.98,,,,,,SUTURE MONOCRYL 4-0 PS-2,,0272,,13.19,9.8925,9.8925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,7.42,3.22,2266.54,,,,,,RELOAD BLUE 40MM (CONTOUR CURVED) (J&J),,0272,,345.49,259.1175,259.1175
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J0171,Adrenalin epinephrine inject [HCPCS J0171],2.5,1.88,1.88,1.67,0.8,1.67,,,,,,SURGICEL HEMOSTAT ABSORBABLE 2X3,,0272,,103.9,77.925,77.925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J0282,Amiodarone hcl [HCPCS J0282],11.54,8.66,8.66,3.34,3.34,7.08,,,,,,"TRAY, IRRIGATION (COVIDIEN)",,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,8.35,5.5,14.67,,,,,,TRAP WATER (ADULT),,0272,,40.89,30.6675,30.6675
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,4.18,0.68,2868.2,,,,,,"ADAPTOR AIRWAY, ELBOW",,0272,,10.87,8.1525,8.1525
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,1.67,0.11,332.88,,,,,,BLADE SURGICAL CLIPPER 9680,,0272,,7.53,5.6475,5.6475
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J1610,Glucagon hydrochloride/1 mg [HCPCS J1610],409.2,306.9,306.9,273.3,180.05,273.3,,,,,,SUTURE PROLENE MESH (PMH),,0272,,79.86,59.895,59.895
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,1.67,1.1,3.07,,,,,,NEEDLE BIOPSY MONOPTY CORE,,0272,,85.22,63.915,63.915
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J1650,Inj enoxaparin sodium [HCPCS J1650],14.44,10.83,10.83,0.71,0.47,8.78,,,,,,"SUTURE, 5-0 ETHILON G695G",,0272,,12.48,9.36,9.36
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,8.27,5.5,1162.88,,,,,,"TUBING, INSUFFLATOR (SUB)",,0272,,27.02,20.265,20.265
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,16.7,0.73,808.23,,,,,,SURGICEL HEMOSTAT ABSORBABLE 4X8,,0272,,186.44,139.83,139.83
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,8.27,7.08,29.34,,,,,,HOOK SHARP 5MM,,0272,,21.72,16.29,16.29
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,16.53,7.8,30.4,,,,,,FISCHER CONE BIOPSY EXCISOR (MEDIUM),,0272,,43.91,32.9325,32.9325
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,16.54,3.15,30.39,,,,,,ALLEVYN 5X5 ADHESIVE DRESSING,,0272,,13.71,10.2825,10.2825
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,16.54,11,29.34,,,,,,TRAY CATHETER INSERTION 30CC,,0272,,6.3,4.725,4.725
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,8.35,0.95,3583.7,,,,,,SPONGE POST OP 4X4,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,5.57,1.72,16.28,,,,,,HOLDER TUBE MULTI PURPOSE,,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,16.7,2.81,811.33,,,,,,DRESSING OPTIFOAM 5X4,,0272,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.84,0.55,29.34,,,,,,STAT LOCK CATHETER DEVICE,,0272,,10.91,8.1825,8.1825
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,19.23,5.49,347.63,,,,,,TRAY LACERATION (MEDICHOICE),,0272,,19.9,14.925,14.925
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,15.93,5.5,19.14,,,,,,TRAP TISSUE SAFETOUCH (BERKELEY),,0272,,26.1,19.575,19.575
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],20,15,15,3.34,0.84,14.68,,,,,,CUFF BLD PRESS DISP SMALL ADULT 1 TUBE,,0270,,14.61,10.9575,10.9575
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,13.23,1.66,23.47,,,,,,CUFF BLD PRESS DISP REG ADULT 1 TUBE,,0270,,17.66,13.245,13.245
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,13.3,1.76,23.48,,,,,,CUFF BLD PRESS DISP LG ADULT 1 TUBE,,0270,,18.46,13.845,13.845
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,23.38,0.02,4433.9,,,,,,CUFF BLD PRESS DISP CHILD 1 TUBE,,0270,,14.51,10.8825,10.8825
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,0,2.4,4.25,,,,,,NIPPLE SHIELD 20MM,,0270,,15.18,11.385,11.385
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,J7633,Budesonide non-comp con [HCPCS J7633],27.7,20.78,20.78,0,9.12,482.83,,,,,,NURSING PADS (MEDELA),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,337.23,167.53,728.8,,,,,,ENDOCUFF VISION LG (GREEN),,0272,,54.9,41.175,41.175
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,790,Anesthesia provided during procedure in upper abdomen with use of an endoscope [HCPCS 00790],139,104.25,104.25,2.01,1.97,425.11,,,,,,ADAPTOR AUXILIARY CHANNEL,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,11043,Skin and muscle removal (first 20 sq cm or less) [HCPCS 11043],369.98,277.49,277.49,146.51,146.51,146.51,,,,,,PASTE STOMAHESIVE 2OZ,,0270,,13.39,10.0425,10.0425
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,11406,"Removal of non-cancerous skin lesion of trunk, arms, or legs (over 4.0 cm) [HCPCS 11406]",1250.3,937.73,937.73,238.72,238.72,397.16,,,,,,NEEDLE FILTER 19GX1 (SUB),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,246.4,168.37,416.16,,,,,,"TRAY, SPINAL ANESTHESIA 25GX3-1/2(ARROW)",,0272,,40.95,30.7125,30.7125
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,47564,Gallbladder removal with inspection of common bile duct with endoscope [HCPCS 47564],2968.93,2226.7,2226.7,1073.41,1073.41,1073.41,,,,,,LONESTAR RETRACTOR,,0272,,117.11,87.8325,87.8325
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,49083,Abdominal cavity fluid drainage with imaging guidance [HCPCS 49083],81.2,60.9,60.9,80.39,80.39,80.39,,,,,,PACK ICE/LG CLIP CLOSURE (SUB),,0270,,5,3.75,3.75
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,350.31,214.38,2255.8,,,,,,CONTROL A FLO IV (SUB),,0272,,14.89,11.1675,11.1675
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,288.11,242.91,1540,,,,,,NEEDLE COUNTER (SUB),,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,55.05,13.55,72.8,,,,,,"TAPE, PAPER 3",,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,69.25,52.38,170.1,,,,,,DRESSING COBAN 1,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,94.21,52.53,206.9,,,,,,ENVELOPE # 10 NO WINDOW (RCH LOGO),,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,126.78,81.71,178.67,,,,,,MASK W/ EAR LOOP SPLASH PROTECTOR,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],371.6,278.7,278.7,173.2,122.95,194.97,,,,,,METRICIDE 28 2.5% GAL,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,96.47,59.92,194.57,,,,,,PRINTER HP 53A,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,129.16,95.05,222.03,,,,,,RAPICIDE,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.63,22.37,41.75,,,,,,OIL SHREDDER,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,68.63,39.55,134.08,,,,,,ENVELOPE CLASP 6 X 9,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99226,Subsequent observation care (typically 35 minutes per day) [HCPCS 99226],285.4,214.05,214.05,98.08,98.08,98.08,,,,,,PROBE COVER FOR X-RAY,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,36.93,31.68,51.15,,,,,,THERMOMETER DISPOSABLE SINGLE USE,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,68.96,45.48,91.29,,,,,,MASK CHILD W/LOOP MICKEY MOUSE,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,124.5,114.76,176.55,,,,,,FORM REQUEST FOR RETURN WORK OR SCHOOL,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99236,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of high severity (55 minutes per day) [HCPCS 99236],568.9,426.68,426.68,204.82,191.28,228.53,,,,,,GLASS ORTHO 6,,,,,,
"WELLMED MEDICAL MANAGEMENT, INC. - Medicare-HMO",Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,68.88,59.99,274.04,,,,,,FORM(LONG) FOR PURCHASE,,,,,,
WESTERN SKY COMMUNITY CARE INC - Commercial-HMO,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,57.76,57.76,225,,,,,,FORM (SHORT) FOR PURCHASE,,,,,,
WESTERN SKY COMMUNITY CARE INC - Commercial-HMO,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,56.37,56.37,178.99,,,,,,PRINTER BROTHER FAX PC201 (PHARMACY),,,,,,
WESTERN SKY COMMUNITY CARE INC - Commercial-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,133.17,61.48,2109.82,,,,,,LABELS I.V. 96 HR.,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,93.54,55,125,,,,,,LABELS SAME NAME,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.68,2.44,580.94,,,,,,CONNECTOR CUFF FEMALE LUER LOCK SLIP,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,59,20.71,250.4,,,,,,HOLDER SUCTION CANISTER 1500CC WALL MOUN,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,180.22,180.22,3324.06,,,,,,FOLDER GREEN END-TAB (CLINIC) OD,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,9.43,8.87,355.2,,,,,,JACKET BLUE MEDIUM OR,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,15.3,14.4,297.7,,,,,,PATCH PROBE HEAT REFLECTING L/D,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,2.83,2.66,76.2,,,,,,BABY SCALE LINERS,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,5.82,5.81,65.1,,,,,,ADDING MACHINE PAPER (OFFICE DEPOT),,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,0,11.55,98.31,,,,,,ALCOHOL PREP PAD,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,6.16,5,105.9,,,,,,BANDAGE PLASTER 2,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,11.13,9.87,141.2,,,,,,BANDAGE PLASTER 3,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,6.94,6,88.2,,,,,,BANDAGE PLASTER 6,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,45.82,45.82,378.9,,,,,,BANDAGE PLASTER 4,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,31.33,29.48,105,,,,,,BANDAGE PLASTER 5,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,0,6.15,4344.87,,,,,,COTTON TIP OB 16 LENGTH,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,24.39,16.26,2475.42,,,,,,BANDAID SPOTS,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,24.39,4.51,1156.79,,,,,,BANDAID X LARGE (CARDINAL),,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,35.57,29.4,2785.69,,,,,,BANDAID STRIP 1,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,35.57,12.56,48.28,,,,,,BATTERIES D (OFFICE DEPOT),,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,83.46,39.1,434.06,,,,,,BRUSH BETADINE,,0270,,5,3.75,3.75
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,212.01,50,3116.59,,,,,,BETADINE SOLUTION 4 OZ(do not use),,0270,,5,3.75,3.75
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,313.24,62.92,1098.7,,,,,,BOGGAN BABY CAP,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,24.3,5.83,3301.98,,,,,,BOOT FULL COV. N/SKID,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,J0171,Adrenalin epinephrine inject [HCPCS J0171],2.5,1.88,1.88,0,0.8,1.67,,,,,,BRUSH DRY SCRUB,,0270,,5,3.75,3.75
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0,0.73,808.23,,,,,,CAP SURGEON DISP.,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,0,11,29.34,,,,,,CAPE PAPER TISSUE,,,,,,
WESTERN SKY COMMUNITY CARE INC - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,0,0.95,3583.7,,,,,,CAPS BOUFFANT BLUE,,,,,,
AMBETTER - Medicaid,,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,71.13,52.38,170.1,,,,,,CIDEX PLUS QUART,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,16.71,2.44,580.94,,,,,,CLEANER WASH CLOTH,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],11326.9,8495.18,8495.18,4250.36,2696.69,4250.36,,,,,,COTTON APPLICATOR,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,70460,"Head or brain CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 70460]",1319.8,989.85,989.85,1049.9,1041.32,1049.9,,,,,,CUP PAPER MEDICINE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,189.65,20.71,250.4,,,,,,CUP DENTURE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,205.48,28.74,271.3,,,,,,CUP PLASTIC MEDICINE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,178.99,94.25,214.2,,,,,,CURETTE EAR LOOP,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,178.99,56.37,178.99,,,,,,DEODORANT,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,170.4,37.7,213.75,,,,,,DETERGENT (SKLAR KLEEN),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",694.6,520.95,520.95,526.22,166.13,526.22,,,,,,DIAPER XLG ADULT,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,170.4,90,225,,,,,,DIAPER ADLT-LG,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1980.4,180.22,3324.06,,,,,,DIAPERS MED 14PK.,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1901.96,561.23,2500,,,,,,DIAPERS PREEMIE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,128.08,8.49,161,,,,,,DIAPERS TODDLER SZ 4,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,195.69,8.87,355.2,,,,,,DIAPERS TODDLER SZ. 4,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,118.45,11.25,148.9,,,,,,DRAPE UNDER BUTTOCKS,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,80202,Lab analysis to measure the amount of vancomycin (antibiotic) in serum specimen [HCPCS 80202],158.8,119.1,119.1,120.28,66.53,120.28,,,,,,DRAPE FO0TSWITCH,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,80299,Lab analysis of therapeutic drug not elsewhere specified [HCPCS 80299],277.9,208.43,208.43,0,146.11,146.11,,,,,,DRAPE U RCH CLINIC,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,236.82,14.4,297.7,,,,,,ELECTRODE EKG TABS 5500 Q TRACE RESP CAR,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,68.41,9.42,73.71,,,,,,ELECTRODE INFANT (KCAT),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,60.62,2.66,76.2,,,,,,ELECTRODE INFANT (KCAT) CARDINAL,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,42.16,1.89,53,,,,,,ENVELOPE# 10 W/WINDOW 500,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,64.91,6.2,81.6,,,,,,ENVELOPES #10 COLUMBIAN (NO WINDOW),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,72.71,5.44,96,,,,,,FECAL ODOR ELIMINATOR,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,51.79,5.81,65.1,,,,,,FILM CAMERA UPC-55,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,78.99,11.55,98.31,,,,,,ENVELOPE SECURITY RCH # 10 (WINDOW),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,6.92,2.66,8.7,,,,,,FORM 2010 NEWBORN ID,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,87.74,8.16,104.31,,,,,,FORM XRAY PKG,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,147.01,9.72,190.22,,,,,,FORM AFTERCARE INSTRUCTIONS ER,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,80.19,5,105.9,,,,,,FORM CROSSMATCH,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,57.91,5.63,72.8,,,,,,FORM INSURANCE CLAIM 1500 1PT.,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,224.57,32.98,268.8,,,,,,FORM MAINTENANCE REQUEST,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,107.95,14.11,134.34,,,,,,FORM TRANSFUSION REPORT,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,112.32,9.87,141.2,,,,,,GEL ULTRASOUND (BLUE PARKER),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,49.16,7.65,55.26,,,,,,GLOVES N/L X-LRG.,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,70.16,6,88.2,,,,,,GLOVES N/L SM,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,152.66,8.55,182.7,,,,,,GLOVES N/L MED,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,55.37,3.6,69.6,,,,,,GLOVES N/L LG,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,55.37,6.03,69.6,,,,,,GLOVES STRL SZ 7 1/2 N/LATEX (green box),,0270,,5.03,3.7725,3.7725
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,106.92,9.2,112.32,,,,,,GLOVES SZ 6.5 N/LATEX POWDER FREE ( darkgreen box),,0270,,5,3.75,3.75
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,0,7.24,496.86,,,,,,GOWN PAPER DISP.,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,0,9.38,86.39,,,,,,GOWN YELLOW,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,76.05,6.79,100.4,,,,,,HAIR CARE COMFORT,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,81.86,2.84,108.1,,,,,,HIBICLENS SOAP BOTTLE 32 oz.,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,18.77,6.8,52.43,,,,,,HIGHLIGHTER PINK (OFFICE DEPOT),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,130.3,7.27,172,,,,,,HIGHLIGHTER YELLOW (OFFICE DEPOT),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,39.3,4.29,39.3,,,,,,K-Y JELLY PACKETS,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,117.81,8.17,155.5,,,,,,KIT ADMIT,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,123.7,29.48,155.5,,,,,,LAB COAT LARGE,,,,55.16,41.37,41.37
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,123.7,29.48,155.5,,,,,,LAB COAT MEDIUM,,,,55.16,41.37,41.37
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,125.29,45.82,378.9,,,,,,LAB COAT SMALL,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,79.55,29.48,105,,,,,,LAB COAT X-LARGE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,88304,Pathology lab analysis of tissue with microscope (moderately low complexity) [HCPCS 88304],33.1,24.83,24.83,25.06,25.06,25.06,,,,,,LAB COAT 2X-LARGE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,92.76,6.15,4344.87,,,,,,LAB COAT 3X LARGE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,63.48,16.49,98.36,,,,,,LABELS 3 1/2 X 15/16,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,63.48,19.15,448.97,,,,,,PAPER MATE CORRECTION TAPE (OD),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,355.27,28.6,1161.38,,,,,,MASK PARTICULATE N95 SMALL(1860S),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,73.5,16.26,2475.42,,,,,,MASK ANTIFOG(HALYARD),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,338.33,68.61,524.17,,,,,,MASK MOLDED FACE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,58.47,20.72,3197.1,,,,,,MASK W/EYE SHIELD AND FOG FREE(KYMBERLY CLARK),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,70.16,34.19,143.78,,,,,,MASK DUCKBILL,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96368,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (concurrent with another infusion) [HCPCS 96368]",92.7,69.53,69.53,70.16,38.81,108.8,,,,,,MAT SURGISAFE ABSORBENT,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,59.34,4.51,1156.79,,,,,,MATTRESS EGG CRATE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,158.78,29.4,2785.69,,,,,,MEASURING TAPE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,30.07,12.56,48.28,,,,,,MULTISTIX,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,29.83,10.24,44.01,,,,,,NEEDLE 25G 5/8,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,194.74,39.1,434.06,,,,,,NEEDLE HUBER 20G 3/4,,0270,,8.15,6.1125,6.1125
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,306.19,61.48,2109.82,,,,,,NEEDLE 20G1,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,431.88,50,3116.59,,,,,,NEEDLE 21G1 1/2,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,744.67,62.92,1098.7,,,,,,NEEDLE 22G 1(ANESTHESIA),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,18.38,5.83,3301.98,,,,,,NEEDLE 25 G 1,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,4.97,0.68,2868.2,,,,,,NEEDLE 18G1,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,1.99,0.11,332.88,,,,,,NEEDLE 22G1 1/2,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,19.89,0.73,808.23,,,,,,NEEDLE 23G1,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,19.89,7.08,29.34,,,,,,NEEDLE 25G1 1/2,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,9.95,5.5,14.67,,,,,,NEEDLE 27G 1 1/4,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,19.89,3.15,30.39,,,,,,NPH KLENZ/PROLYSTICA 2X (NEW NPH KLENZ),,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,19.89,11,29.34,,,,,,ORTHOZYME 1 GL,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,9.95,0.95,3583.7,,,,,,PAD DESK CALENDAR 2018,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,6.63,1.72,16.28,,,,,,PAD BETADINE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.99,0.55,29.34,,,,,,PAD NURSING DISPOSABLE,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,23.13,5.49,347.63,,,,,,PADDING CAST WEBRIL 3,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,5.07,1.29,348.28,,,,,,PADDING CAST WEBRIL 6,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,19.14,5.5,19.14,,,,,,PADDING CAST WEBRIL 4,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,15.91,1.76,23.48,,,,,,PADDING CAST WEBRIL 2,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,27.84,0.02,4433.9,,,,,,PADDING SPECIAL 6,,,,,,
AMBETTER - Medicaid,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,3.98,2.4,4.25,,,,,,PAD O.B. PKG,,,,,,
AMBETTER - Medicaid,Skilled Nursing Facility,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,352,4.8,352,,,,,,PAN BED/DISPOSABLE,,,,,,
AMERIBEN SOLUTIONS - Commercial-Indemnity,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,0,13.55,72.8,,,,,,PAN FRACTURE,,,,,,
AMERIBEN SOLUTIONS - Commercial-Indemnity,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,PAPER EXAM ROLL,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,92.72,4.51,1156.79,,,,,,PAPER STERIS (SURGERY STERILIZER),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,PAPER 8 1/2 X 11 (STAPLES),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,PAPER DATASCOPE (TRIO),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,258.3,107.28,315.01,,,,,,PAPER FETAL MONITOR,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,2894.06,393.52,2894.06,,,,,,PENCILS #2 MED,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,70.32,55,125,,,,,,PILLOW REUSABLE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.85,2.44,580.94,,,,,,PILLOWCASE DISP.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",3443.56,2582.67,2582.67,1861.53,1202.14,1861.53,,,,,,PITCHER,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,119.94,119.94,617.26,,,,,,POUCH INST 3 1/2 X 8,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,57240,Bladder hernia repair into vaginal wall repair [HCPCS 57240],8623.24,6467.43,6467.43,3445.76,3445.76,3445.76,,,,,,POUCH INST 5.25x10,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,890.33,137.3,1347.57,,,,,,POUCH INSTRUMENT 7 X 13,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,141.8,20.71,250.4,,,,,,SLIPPER YELLOW CHILD,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,154.64,28.74,271.3,,,,,,RAZOR DISP.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,128.25,94.25,177.23,,,,,,RECEPTACLE LG 8.2 QUART,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,148.6,109.96,166.13,,,,,,RECEPTACLE SMALL 1.5 Q,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,754.11,137.3,1124.55,,,,,,RECEPTACLE WALL 5.4 QT,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,126.58,4.45,148.78,,,,,,RECEPTACLE X-LG 19.7 QT. (5 GALLON),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,122.09,69.84,223.7,,,,,,REMOVER NAIL POLISH,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,127.42,4.41,166.13,,,,,,SHAVING CREAM 2 OZ.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,738,166.13,1107.72,,,,,,SHEET DRAW,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,749.21,166.13,1309.77,,,,,,SHEET DRAPE N/S (WHITE),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,126.58,94.25,222.4,,,,,,SHIRT INFANT DISP.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,127.42,25.73,191.25,,,,,,SHOE COVERS NON SKID,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,127.42,24.39,148.78,,,,,,"WIPE, SKIN PREP 50/BOX",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,126.58,18.85,148.78,,,,,,SLIPPERS INFANT WHITE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,126.58,33.08,182.07,,,,,,SLIPPERS ADT-LG(BROWN),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,126.58,99,166.13,,,,,,SLIPPERS ADT-XLG (GREY),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73501,Hip x-ray of hip with pelvis (single view) [HCPCS 73501],225,168.75,168.75,127.42,49.24,127.42,,,,,,SLIPPERS ADT-XXLG,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,127.42,57.76,225,,,,,,SLIPPERS MED BLUE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,94.25,94.25,214.2,,,,,,SOAP BAR (do not use),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,128.25,37.7,213.75,,,,,,SODASORB PREPAK,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,127.42,90,225,,,,,,CUP (NON STERILE) SPECIMEN,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1409.81,180.22,3324.06,,,,,,SPECULA 2.5MM,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1421.7,561.23,2500,,,,,,SPECULA 4.25 MM,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",4712.1,3534.08,3534.08,1778.18,561.23,2284.78,,,,,,SPONGE 4X4 NONSTERILE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,0,166.13,421.2,,,,,,SPONGE 2X2 N/S,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,370.3,107.93,965.26,,,,,,STOCKINETTE 2,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,317.86,166.13,1065.48,,,,,,STOCKINETTE 3,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,76.67,23.61,157.86,,,,,,STOCKINETTE 4,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,203.5,108.36,412.85,,,,,,STOCKINETTE 6,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,91.09,89.59,349.41,,,,,,STRAP PINK & BLUE TRANSDUCER,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,90.85,8.49,161,,,,,,SYRINGE 50CC,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,"SYRINGE, INSULIN 1 CC",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,84.02,11.25,148.9,,,,,,"SYRINGE, 5 CC",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80202,Lab analysis to measure the amount of vancomycin (antibiotic) in serum specimen [HCPCS 80202],158.8,119.1,119.1,89.61,66.53,120.28,,,,,,"SYRINGE,INSULIN 1/2CC",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,167.99,14.4,297.7,,,,,,TAPE CLEAR WIDE SCOTCH (OFFICE DEPOT),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,49.02,9.42,73.71,,,,,,"TAPE, AUTOCLAVE",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,58.21,9.63,285.09,,,,,,"TAPE, ELASTIKON 3",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,42.56,2.66,76.2,,,,,,"TAPE, PAPER 1/2",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,29.91,1.89,53,,,,,,"TAPE, PAPER 1",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,15.11,2.31,20.91,,,,,,"TAPE, PAPER 2",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,36.37,5.81,65.1,,,,,,"TAPE, SILK 1/2",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,56.03,11.55,98.31,,,,,,"TAPE, SILK 1",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,28.05,5.2,40.9,,,,,,"TAPE, SILK 2",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,55.35,4.35,81.23,,,,,,"TAPE, SILK 3",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,49.72,12.67,98.39,,,,,,"TAPE, TRANSPORE",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,0,32.34,465.3,,,,,,"TEST,DART",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,5.14,2.66,8.7,,,,,,TONGUE BLADES,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,65.4,8.16,104.31,,,,,,MOISTURIZER MOUTH LIP,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,109.53,9.72,190.22,,,,,,"SWAB, TOOTHETTES(do not use)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,59.76,5,105.9,,,,,,TUBEGAUZE 1,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,41.08,5.63,72.8,,,,,,TUBEGAUZE 3,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,159.3,32.98,268.8,,,,,,TUBEGAUZE 4,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,0,18.45,315.4,,,,,,TUBEGAUZE 5,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84154,Lab analysis to measure the amount of free PSA (prostate specific antigen) in serum specimen [HCPCS 84154],222.7,167.03,167.03,125.67,93.32,135.4,,,,,,TUMBLER,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,73.42,7.58,134.6,,,,,,SURGISTAIN STAIN REMOVER,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,76.58,14.11,134.34,,,,,,"UNDERPADS, REG BLUE",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,87.75,14.41,153.94,,,,,,"UNDERPADS, XTRA-LG (CARDINAL)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,78.87,9.87,141.2,,,,,,"URINE, STRAINER",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,29.91,4.02,32.1,,,,,,"WRAP,STERILE QUICK CHECK 24 X 24",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,110.15,17.05,191.3,,,,,,PAPER LIFEPAK 50MM PAPER,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,TOOTHBRUSHES,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,15.71,5.43,37.5,,,,,,DIAPER JUMBO SZ. 6,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,107.19,8.55,182.7,,,,,,EYE GUARD ANESTHESIA,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,39.27,3.6,69.6,,,,,,TOWELETTE OB RCH/1192,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,38.93,2.7,54.33,,,,,,"BANDAGE,COMPRESSION SYSTEM COBAN 2 LAYE",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,39.27,6.03,69.6,,,,,,PULL UP DIAPER FOR ADULT MEDIUM,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,43.43,5.26,76.2,,,,,,PULL UP DIAPER FOR ADULT LARGE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,68.45,11.52,121.3,,,,,,PULL UP DIAPER FOR ADULT XL,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,79.68,9.2,112.32,,,,,,DIAPER SZ. 5,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,56.66,6.79,100.4,,,,,,SHARPS CONTAINER WALL BRACKET 5.4QT.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,43.12,2.84,108.1,,,,,,SUPER SANI-CLOTH WIPES,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,9.89,6.8,52.43,,,,,,SCRUB SOLUTION PVP 7.5%,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,97.06,7.27,172,,,,,,PROBE KIT ORAL 4FT.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,86.87,8.17,155.5,,,,,,PROBE KIT 9FT ORAL,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,92.39,45.82,378.9,,,,,,BATTERIES AA (OFFICE DEPOT),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,58.65,29.48,105,,,,,,BATTERIES AAA (OFFICE DEPOT),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,18.62,13.86,24.19,,,,,,BATTERIES C (OFFICE DEPOT),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,68.92,6.15,4344.87,,,,,,BATTERIES 9V (OFFICE DEPOT),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,93308,Heart ultrasound (follow-up or limited) [HCPCS 93308],459.8,344.85,344.85,258.69,258.69,258.69,,,,,,SCISSORS UTILITY 7 1/4IN.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,251.26,28.6,1161.38,,,,,,PAD DESK CALENDAR 2022,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,43.72,16.26,2475.42,,,,,,PROBE KIT RECTAL 4FT.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,187.13,68.61,524.17,,,,,,SCRUB PVP PREP SOLUTION 4OZ,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,38.72,20.72,3197.1,,,,,,CONTAINER SHARPS 8 GAL RED (BEMIS),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,92.72,4.51,1156.79,,,,,,DUST CLEANING CANNED AIR 10 oz. (OD),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,113.03,29.4,2785.69,,,,,,WIPES BABY (PAMPERS) SENSITIVE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.49,12.56,48.28,,,,,,PRINTER HP 05A (2-PACK),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,21.24,10.24,44.01,,,,,,FORM LAB OUT/PATIENT MEDICARE & MEDICAID,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,64.13,40.84,136.8,,,,,,RUBBER BANDS (SMALL PKG),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,47.77,23.51,98.36,,,,,,JACKET BLUE SMALL (SURGERY),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,208.05,140.59,428.4,,,,,,"SYRINGE, 10 CC (Henry Schein)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97597,Tissue removal from wounds per session (first 20 sq cm or less) [HCPCS 97597],709,531.75,531.75,297.09,85.58,468.8,,,,,,BAG BIOHAZARD( O&M),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97605,Wound vac therapy (negative pressure wound therapy) with DME (durable medical equipment) per session (surface area less than or equal to 50 square cm) [HCPCS 97605],709,531.75,531.75,401.51,215.54,401.51,,,,,,"SYRINGE, 12 CC (COVIDIEN)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,296.25,35.11,337.46,,,,,,GLASS ORTHO 1,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,GLASS ORTHO 2,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,102.56,39.1,434.06,,,,,,GLASS ORTHO 3,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,217.97,61.48,2109.82,,,,,,GLASS ORTHO 4,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,320.74,50,3116.59,,,,,,GLASS ORTHO 5,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,530.12,62.92,1098.7,,,,,,CUFF BLD PRESS-DISP LARGE ADULT 11,,0270,,32.9,24.675,24.675
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,62.22,2.42,250.2,,,,,,CUFF BLD PRESS-DISP LARGE ADULT 12,,0270,,32.9,24.675,24.675
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,G0328,Fecal blood scrn immunoassay [HCPCS G0328],48.8,36.6,36.6,27.26,20.42,48.31,,,,,,CUFF BLOOD PRESS. ADULT THIGH,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,13.67,5.83,3301.98,,,,,,CUFF BLOOD PRESS. SMALL CHILD,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,13.67,7.4,19.63,,,,,,CUFF BLOOD PRESS. SMALL ADULT,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,6.33,3.22,2266.54,,,,,,SHAMPOO/APLICARE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J0282,Amiodarone hcl [HCPCS J0282],11.54,8.66,8.66,6.53,3.34,7.08,,,,,,LABELS YEAR 500BX 2020,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J0330,Succinycholine chloride inj [HCPCS J0330],3.95,2.96,2.96,2.22,1.74,3.04,,,,,,LOTION (JOHNSON'S)1.7OZ.,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2.75,0.68,2868.2,,,,,,GLOVES NITRILE EXAM SIZE MEDIUM (TRONEX),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,1.43,0.11,332.88,,,,,,GLOVES NITRILE EXAM SIZE SMALL (TRONEX),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,1.41,0.73,808.23,,,,,,PRINTER CARTRIDGE OKIDATA B6500 (PHARM),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,14.06,7.08,29.34,,,,,,ENVELOPE MOISTENER BOTTLE (OD),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,7.03,5.5,14.67,,,,,,GOWN FLUID RESISTANT,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,14.25,3.15,30.39,,,,,,TONER BLACK CS310 LEXMARK,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,14.25,11,29.34,,,,,,TONER YELLOW CS310 LEXMARK,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2370,Phenylephrine hcl injection [HCPCS J2370],25,18.75,18.75,14.25,14.25,14.25,,,,,,TONER CYAN CS310 LEXMARK,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.13,0.95,3583.7,,,,,,GOWN(95131) STANDARD ULTRA XX-LG,,0270,,12.88,9.66,9.66
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,3.67,1.72,16.28,,,,,,MASK N95/ SIZE MEDIUM (GRAINGER),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.71,0.55,29.34,,,,,,SOAP CASTILE TOWLETTE,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,3.59,1.29,348.28,,,,,,IMAGING UNIT 50F0Z00 MS410 LEXMARK,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,7.79,5.5,19.14,,,,,,"THERMOMETER, MERCURY FREE DIGITAL",,0270,,12.85,9.6375,9.6375
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],20,15,15,2.83,0.84,14.68,,,,,,PRINTER INKJET 564XL BLACK (PHOTO),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,1.76,23.48,,,,,,BOOT COVERS KNEE HIGH,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,0,0.02,4433.9,,,,,,SCRUB E-Z/ HIBICLENS (CARDINAL),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,U0004,"2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r [HCPCS U0004]",89.3,66.98,66.98,39.29,39.29,43.47,,,,,,"DISPENSER, EME BAG",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],3522.49,2641.87,2641.87,0,179.75,1202.14,,,,,,BAG EME (MEDLINE),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],4605.38,3454.04,3454.04,15.34,15.34,2509.37,,,,,,PILLOW REUSABLE 20x26 (CARELINE),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],4243.39,3182.54,3182.54,246.83,246.83,3309.99,,,,,,FETAL MONITOR BELT (NEW),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],103.1,77.33,77.33,37.53,35.33,37.53,,,,,,PRINTER HP 74 BLACK,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,0,3.97,330,,,,,,MASK PROCEDURE (MEDICHOICE),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel procedure with endoscope [HCPCS 00813]",139,104.25,104.25,0,5.44,556,,,,,,URINAL (MEDICHOICE),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,940,"Anesthesia provided during vaginal biopsy of cervix, uterine lining, or external genitalia [HCPCS 00940]",139,104.25,104.25,0,6.53,6.53,,,,,,MASK SURGICAL,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,10061,Abscess incision and drainage (complicated procedure or multiple abscesses) [HCPCS 10061],638.4,478.8,478.8,176.75,176.75,327.9,,,,,,MASK PROCEDURE (MEDLINE),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1340.7,1005.53,1005.53,65.83,65.83,226.6,,,,,,DRAPE STERI,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,175.57,51.74,302.2,,,,,,"BINDER D-RING 1"" (HEAVY DUTY)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,57240,Bladder hernia repair into vaginal wall repair [HCPCS 57240],2907.4,2180.55,2180.55,299.73,299.73,299.73,,,,,,"BINDER D-RING 2"" (HEAVY DUTY)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,57288,Sling around bladder canal (urethra) creation to control leakage [HCPCS 57288],2016.9,1512.68,1512.68,725.76,725.76,725.76,,,,,,"BINDER D-RING 3"" (HEAVY DUTY)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,68.14,52.38,170.1,,,,,,"BINDER D-RING 4"" (HEAVY DUTY)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,127.04,81.71,178.67,,,,,,"BINDER D-RING 5"" (HEAVY DUTY)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,95.7,59.92,194.57,,,,,,PATCH HEAT REFLECTORS,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,129.42,95.05,222.03,,,,,,PROBE COVERS WA (SUB),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,37.33,22.37,41.75,,,,,,PAPER COPY 8 1/2 X 11 (OD),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,67.53,39.55,134.08,,,,,,"LANCET, FINGERSTICK (MEDICHOICE)",,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,37,31.68,51.15,,,,,,PAPER COPY 8 1/2 X 14 (OD),,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,68.41,45.48,91.29,,,,,,BLADE LARYNGOSCOPE SZ 2,,0270,,20.83,15.6225,15.6225
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,69.02,59.99,274.04,,,,,,PULL UP DIAPER MED/SMALL,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,296.06,70.45,319.43,,,,,,PEN BLACK (OFFICE DEPOT),,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,8.8,2.44,580.94,,,,,,"POST IT SMALL 1 1/2"" X 2 (OFFICE DEPOT)",,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1052,561.23,2500,,,,,,PAD LEGAL (YELLOW) OFFICE DEPOT,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,8.87,355.2,,,,,,ENVELOPE CLASP 9X12 (OFFICE DEPOT),,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,31.9,2.66,76.2,,,,,,PROBE COVER (X-RAY),,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,44.35,5,105.9,,,,,,RESTRAINT WRIST,,0270,,8.07,6.0525,6.0525
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,NEEDLE 27G X 1/2 1.0ML,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.06,6.79,100.4,,,,,,GLOVES SMALL (NITRILE) SILVER,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,45.28,2.84,108.1,,,,,,SYRINGE 3CC W/ NEEDLE,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,10.38,6.8,52.43,,,,,,"UNDERPADS, 17X24",,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.07,7.27,172,,,,,,ELECTRODE ECG 530,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,FOLDERS LIGHT BLUE (CLINIC),,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,187.13,68.61,524.17,,,,,,FOLDERS RED (CLINIC),,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,16.63,12.56,48.28,,,,,,SOLUTION DURAPREP,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,238.88,50,3116.59,,,,,,"WRAP,STERILE QUICK CHECK 36 X 36",,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2.75,0.68,2868.2,,,,,,"WRAP,STERILE QUICK CHECK 45 X 45",,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,11,3.15,30.39,,,,,,SOLUTION DURAPREP 26ML,,,,,,
AMERICAN INSURANCE ADMINISTRATOR - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,5.5,0.95,3583.7,,,,,,LABELS PIGGYBACK (YELLOW),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-Mut Defined",Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,2255.8,214.38,2255.8,,,,,,RIBBON THERMAL TRANSFER (CPSI),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,3.53,2.09,3.53,,,,,,PAPER UPP-110HD SONY,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,8.75,6.2,81.6,,,,,,LABELS PIGGYBACK (PHARMACY),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",92.7,69.53,69.53,236.82,5.3,236.82,,,,,,SUPER SANI-CLOTH WIPES W/BLEACH,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,115.41,105.86,1389.2,,,,,,CUP FOAM 12OZ,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,146.36,35.11,337.46,,,,,,CUFF BLOOD PRESS. LARGE ADULT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,299.06,70.45,319.43,,,,,,CUFF BLOOD PRESS. ADULT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99306,Initial nursing facility visit by admitting physician for problem of high severity (typically 45 minutes per day) [HCPCS 99306],759.7,569.78,569.78,231.95,231.95,368,,,,,,CUFF BLOOD PRESS. CHILD,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,236.82,236.82,316.64,,,,,,"TAPE, HYPAFIX 2x2",,0270,,10.25,7.6875,7.6875
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,236.82,236.82,344.55,,,,,,PAPER MEDICAL PRESCRIPTION,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,231.95,231.95,364.61,,,,,,FOLDERS PENDAFLEX END TAB W/FASTENERS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],65.1,48.83,48.83,0,62,62,,,,,,HEMOCCULT TEST SINGLE SLIDE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,240.69,65.1,240.69,,,,,,BLADE LARYNGOSCOPE SZ 1,,0272,,20.83,15.6225,15.6225
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,240.69,65.1,240.69,,,,,,BLADE LARYNGOSCOPE MAC SIZE 2,,0272,,20.83,15.6225,15.6225
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],65.1,48.83,48.83,240.69,68.4,240.69,,,,,,PRINTER CARTRIDGE HP 80A,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,0,6.13,13.93,,,,,,PRINTER DRUM (BROTHER DR 350),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,J1644,Inj heparin sodium per 1000u [HCPCS J1644],2.5,1.88,1.88,0,1.1,3.07,,,,,,APRON WHITE (MEDICHOICE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0,0.63,1.44,,,,,,PAN BED/DISPOSABLE ROSE (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Institutional,Outpatient,T1015,Clinic service [HCPCS T1015],105.91,79.43,79.43,245.75,240.69,245.75,,,,,,ADDING MACHINE ROLLS (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,PAPER CORRECTION TAPE (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,0,1.28,46.3,,,,,,POST IT LARGE (OFFICE DEPOT) 3X3,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,5.3,5.3,5.3,,,,,,TAPE CLEAR PACKAGING (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",5.3,3.98,3.98,5.3,5.3,5.3,,,,,,PRINTER HP 12A (TWIN PACK) OFFICE DEPOT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,0,15.77,25,,,,,,PRINTER LEXMARK E360 (REMAN) (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,0,5.19,5.3,,,,,,TONER T650A11A LEXMARK (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,13.55,13.55,72.8,,,,,,TONER 50F1H00 LEXMARK,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,245.75,62.38,245.75,,,,,,TONER MAGENTA CS310 LEXMARK,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],68.4,51.3,51.3,240.69,68.4,240.69,,,,,,ENVELOPES CLASP 10 X 13 (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,245.75,65.1,245.75,,,,,,COTTON TIP OB 08 LENGTH,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,245.75,55.34,245.75,,,,,,BAG PATIENT BELONGING,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,245.75,65.1,245.75,,,,,,FOLDERS CLASSIFICATION (LIGHT GREEN),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,CUSHION EAR NASAL CANNULA/TUBING,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,DRAPE LAVH (MEDLINE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,STYLET RIGID (ANESTHESIA),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,0,1.1,17.76,,,,,,CANNULA ADULT 10 FT,,0270,,8.73,6.5475,6.5475
AMERIGROUP INSURANCE COMPANY - Medicaid,Clinic,Professional,Outpatient,T1015,Clinic service [HCPCS T1015],105.9,79.43,79.43,245.75,215.52,245.75,,,,,,BRUSH HAND SCRUB WITH 4% CHG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,214.38,214.38,2255.8,,,,,,MARKERS SHARPIE TWIN TIP (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,1402,Chronic obstructive pulmonary disease [Moderate Severity],8574.98,6431.24,6431.24,8832.23,8832.23,8832.23,,,,,,TRAP WATER DRYLINE ANES,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,3832,Cellulitis & other skin infections [Moderate Severity],8105.42,6079.07,6079.07,7248.03,6672.06,7248.03,,,,,,POUCH INSTRUMENT 12x15,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,4222,Hypovolemia & related electrolyte disorders [Moderate Severity],8435.6,6326.7,6326.7,8474.83,8474.83,8474.83,,,,,,MARKER PERMANENT RETRACTABLE (BLACK),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,5401,Cesarean delivery [Minor Severity],1162.2,871.65,871.65,10223.07,9934.47,10223.07,,,,,,FOLDERS FILE 1/3 TAB (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,5402,Cesarean delivery [Moderate Severity],43188.08,32391.06,32391.06,11506.32,11506.32,16450.64,,,,,,PAD STENO (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,5601,Vaginal delivery [Minor Severity],581.1,435.83,435.83,6384.37,3693.45,6384.37,,,,,,PAD JR. LEGAL WHITE (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,5602,Vaginal delivery [Moderate Severity],581.1,435.83,435.83,3623.48,3623.48,7272.33,,,,,,RIBBON CALCULAOR UNIV SPOOL (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,5603,Vaginal delivery [Major Severity],4946.97,3710.23,3710.23,5095.38,3161.21,5095.38,,,,,,STAPLES SWINGLINE STANDARD 1/4 (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,6401,"Neonate birthwt >2499g, normal newborn or neonate w other problem [Minor Severity]",650.6,487.95,487.95,1559.04,1559.04,1559.04,,,,,,PAPER CLIPS SMALL (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,6402,"Neonate birthwt >2499g, normal newborn or neonate w other problem [Moderate Severity]",1876.68,1407.51,1407.51,3273.21,1932.98,3273.21,,,,,,PAPER CLIPS JUMBO (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Inpatient,7202,Septicemia & disseminated infections [Moderate Severity],19576.67,14682.5,14682.5,9768.47,9768.47,14503.33,,,,,,TAPE INVISIBLE (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,0,55,3102.09,,,,,,MARKERS SHARPIE (BLACK) OFFICE DEPOT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,1590.48,393.52,2894.06,,,,,,INSERT THREE-PART OB BANDS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,0,55,125,,,,,,HAND SANITIZER FOAM REFILL PURELL 1200ML,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,0,55,125,,,,,,LABELS ADDRESS WHITE 1 X 2 5/8 (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,31500,Breathing tube insertion into windpipe cartilage with endoscope (emergent) [HCPCS 31500],567.9,425.93,425.93,666.54,237.95,666.54,,,,,,MATTRESS FOAM EGG CRATE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,24.65,2.44,580.94,,,,,,FOLDERS CLASSIFICATION (RED),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,1384.62,494.34,1384.62,,,,,,COMMAND DAMAGE FREE ORGANIZER STRIP,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,51701,Temporary bladder catheter insertion [HCPCS 51701],300.7,225.53,225.53,291.68,291.68,291.68,,,,,,PRINTER HP 201A MAGENTA TONER (CF403A),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],300.7,225.53,225.53,276.5,119.94,617.26,,,,,,PRINTER HP 201A CYAN TONER (CF401A),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],361.7,271.28,271.28,424.53,73.08,424.53,,,,,,PRINTER HP 201A YELLOW TONER (CF402A),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,58120,Widening of the cervix and surgical removal of part of the lining of the uterus by scraping and scooping (non-obstetrical) [HCPCS 58120],4527.58,3395.69,3395.69,1443.07,1443.07,1443.07,,,,,,PRINTER HP 201A BLACK TONER (CF400A),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],6338.06,4753.55,4753.55,4240.7,1272.13,4240.7,,,,,,PHOTO CONTUDCTOR E260 LEXMARK OD,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,58671,Blocking of uterine tubes by device with endoscope [HCPCS 58671],7193.76,5395.32,5395.32,5022.14,1272.13,5022.14,,,,,,PRINTER HP 75 COLOR,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],339.6,254.7,254.7,262.18,81.5,323.4,,,,,,PULL UP DIAPER FOR ADULT XL (MEDICHOICE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,218.78,32.67,218.78,,,,,,GLOVES STERILE LATEX PROTEXIS SIZE 7 1/2 (purple box),,0270,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,70360,Neck x-ray to examine soft tissue for any obstructions and/or foreign bodies within the throat or neck [HCPCS 70360],225,168.75,168.75,101.93,94.25,182.07,,,,,,MATTRESS AIR (STRYKER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,166.13,137.3,1347.57,,,,,,BEADS PARAFFIN (LAVENDER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,166.13,73.48,1221.85,,,,,,GEL BOTTLE ULTRASOUND,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,70491,"Neck CT scan of the soft tissue of the neck with contrast to examine injury, foreign bodies, or tumors [HCPCS 70491]",1319.8,989.85,989.85,0,272.21,553.04,,,,,,HIGHLIGHTER ORANGE (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,123.34,20.71,250.4,,,,,,HIGHLIGHTER GREEN (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,123.34,28.74,271.3,,,,,,BRUSH SCRUB WITH 3%PCMX,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,0,109.96,166.13,,,,,,DRAPE UNDER BUTTOCKS & DRAINAGE PORT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,0,137.3,1124.55,,,,,,DRAPE SAFETY FOR LEG,,0270,,75.03,56.2725,56.2725
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,123.34,4.45,148.78,,,,,,PAPER EXAM (DR. LEWIS TABLE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],246,184.5,184.5,137.3,107.22,162.99,,,,,,DRAPE INCISE ANTIMICROBIAL 23X23,,0270,,21.74,16.305,16.305
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72072,Spinal x-ray of middle spine (3 views) [HCPCS 72072],249.2,186.9,186.9,0,104.41,104.41,,,,,,CUFF BLOOD PRESS. LONG ADULT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],225,168.75,168.75,166.13,69.84,223.7,,,,,,MEDC BONNETS BABY CAP,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,166.13,166.13,1107.72,,,,,,HOLDER ET TUBE ADULT,,0270,,14.11,10.5825,10.5825
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,350.85,350.85,825.61,,,,,,"TISSUE ,FACIAL 2-PLY (MEDC)",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],98.2,73.65,73.65,118.82,41.14,166.13,,,,,,GLOVES PAIR SIZE 6 TRIFLEX,,0270,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72192,"Pelvis CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 72192]",1221.6,916.2,916.2,0,511.9,1221.6,,,,,,JELLY PAP TEST LUBE 4oz.,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,72220,X-ray of sacrum and tailbone (minimum of 2 views) [HCPCS 72220],225,168.75,168.75,123.34,94.25,148.93,,,,,,GLOVES STERILE LATEX PROTEXIS 7.0 (purple box),,0270,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,123.34,94.25,222.4,,,,,,MARKER NIPPLE 1.5MM SKIN WINGS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,123.34,25.73,191.25,,,,,,GLOVES MEDIUM (NITRILE) SILVER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,123.34,24.39,148.78,,,,,,GLOVES LARGE (NITRILE) SILVER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,123.34,18.85,148.78,,,,,,GLOVES NITRILE EXAM SIZE LARGE (TRONEX),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,123.34,33.08,182.07,,,,,,NEEDLE HYPODERMIC 30G 1/2 WITH 1CC SYRIN,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,117.57,99,166.13,,,,,,DIAPERS NEWBORN (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,0,30.08,220.5,,,,,,"UNDERPADS, XTRA-LG (SUB)",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,123.34,94.25,191.25,,,,,,"TAPE, HYPAFIX 2x11",,0270,,16.18,12.135,12.135
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73218,Imaging of arm by MRI without contrast [HCPCS 73218],1046.4,784.8,784.8,350.85,350.85,350.85,,,,,,MARKERS WET-ERASE FINE TIP ASSORTED 8-PK,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73501,Hip x-ray of hip with pelvis (single view) [HCPCS 73501],225,168.75,168.75,123.34,49.24,127.42,,,,,,GLOVES ORTHO 6,,0270,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],225,168.75,168.75,123.34,57.76,225,,,,,,SYRINGE 1CC LL W/O NEEDLE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],225,168.75,168.75,0,94.25,225,,,,,,COVERALL WHITE 3XL(bunny suit),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,123.34,29.4,177.53,,,,,,FOLDERS FILE BLUE 1/3 TAB (OFFICE DEPOT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,123.34,94.25,214.2,,,,,,SWABCAP DISINFECTANT CAP,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,0,73.09,246.59,,,,,,GLOVES SZ 8.0 PROTEXIS LATEX ORTHO,,0270,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73565,"Knee x-ray of both knees, standing (front to back view) [HCPCS 73565]",236,177,177,123.34,101.77,123.34,,,,,,DRAPE LAPAROTOMY ULTRAGARD W/POUCHES,,0270,,25.47,19.1025,19.1025
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,0,94.25,191.25,,,,,,SPONGE COUNTER BAG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,123.34,69.84,225,,,,,,PAPER BUSINESS IVORY 8 1/2 X 11,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,0,56.37,178.99,,,,,,URINAL (MEDEGEN) SUB,,0270,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,123.34,37.7,213.75,,,,,,EYEWEAR PROTECTIVE ASSEMBLED,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",694.6,520.95,520.95,166.13,166.13,526.22,,,,,,FORM HOME HEALTH SUPERVISORY VISITS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,123.34,90,225,,,,,,RIBBON TYPEWRITTER CORRECTABLE FILM,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,166.13,31.41,166.13,,,,,,DIAPERS MED SIZE 3,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,74022,"Abdominal x-ray, complete study including 2 or more views of abdomen and single view of chest [HCPCS 74022]",377.1,282.83,282.83,166.13,158,229.27,,,,,,QUICK DISCONNECT 3/16 (10/BG),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,350.85,180.22,3324.06,,,,,,FILTER SIGMOIDOSCOPE INSUFFLATION,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,561.23,561.23,2500,,,,,,NOVASOURCE RENAL VANILLA 8oz.,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,166.13,110.94,589.78,,,,,,KIT CLEAN-UP O.R,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,0,62.12,274.64,,,,,,RECEPTACLE SHARPS COLLECTOR 19GL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,166.13,166.13,529.3,,,,,,BULB LAMP SPECULA VAGINAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,166.13,137.3,401.67,,,,,,PRINTER INKJET 564XL (CYAN),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,166.13,107.93,965.26,,,,,,PRINTER INKJET 564XL (YELLOW),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",653.9,490.43,490.43,166.13,137.3,397.57,,,,,,PRINTER INKJET 564XL (MAGENTA),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,166.13,137.3,529.3,,,,,,POUCH INSTRUMENT 12x15 (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76811,Abdominal ultrasound of pregnant uterus with fetal and maternal evaluation (single or first fetus) [HCPCS 76811],785,588.75,588.75,350.85,350.85,350.85,,,,,,GOWN XL (REGULAR),,0270,,14.19,10.6425,10.6425
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76815,"Abdominal ultrasound of pregnant uterus limited to fetal position, heart beat, and amniotic fluid volume (1 or more fetuses) [HCPCS 76815]",357.3,267.98,267.98,166.13,166.13,289.17,,,,,,RED THERA-BAND 50yd (PERFORMANCE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,166.13,92.55,635.38,,,,,,LABEL PRECUT LIDOCAINE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76819,Fetal heart ultrasound and monitoring without non-stress testing [HCPCS 76819],517.2,387.9,387.9,137.3,137.3,166.13,,,,,,LABEL PRECUT EPHEDRINE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,166.13,166.13,529.81,,,,,,LABEL PRECUT NEOSYNEPHRINE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,166.13,166.13,1065.48,,,,,,LABEL PRECUT DURAMORPH,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",468.7,351.53,351.53,166.13,166.13,311.42,,,,,,LABEL PRECUT VERSED,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,76870,Imaging of scrotum by ultrasound [HCPCS 76870],468.7,351.53,351.53,166.13,166.13,309.92,,,,,,LABEL PRECUT SUFENTA,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,103.85,23.61,157.86,,,,,,LABEL PRECUT ZOFRAN,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,0,108.36,412.85,,,,,,LABEL PRECUT GLYCOPYRROLATE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,229.84,89.59,349.41,,,,,,YELLOW THERA-BAND 50yd (PERFORMANCE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,8.6,8.49,161,,,,,,LABEL PRECUT NEOSTIGMINE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,362.62,41.68,551.29,,,,,,LABEL PRECUT REGALN,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.73,8.87,355.2,,,,,,WIPES ADULT (MEDICHOICE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,182.52,43.35,182.52,,,,,,NEEDLE VENIPUNCTURE PRO DEVICE 4140,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,13.61,11.25,148.9,,,,,,FORM 4PT HOME HEALTH PHYSICIANS VERBAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,48.41,48.41,364.52,,,,,,FORM PHYSICIANS PHONE VERBAL ORDER (HH),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,8.3,8.3,183.45,,,,,,SHAMPOO READY BATH CAP,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,17.42,14.4,297.7,,,,,,MASK SILVER LAZER (FOG FREE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,63.16,63.16,518.42,,,,,,DOUBLE SIDED PREP RAZOR,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,11.4,9.42,73.71,,,,,,MEDIA LETTER SIZE FOR SDP1000 PRINTER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,0,9.63,285.09,,,,,,HANDLE LARYNGOSCOPE STUBBY,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.22,2.66,76.2,,,,,,HANDLE LARYNGOSCOPE MEDIUM,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,3.53,2.09,3.53,,,,,,ENVELOPE # 10 WINDOW (RCH LOGO),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,2.29,1.89,53,,,,,,FIBERSOURCE HN 1.2,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,8.75,6.2,81.6,,,,,,TONER 51B1000 LEXMARK,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,81511,"Lab analysis of four analytes (afp, ue3, hcg [any form], dia) from maternal serum to identify the risk of fetal birth defects [HCPCS 81511]",657.1,492.83,492.83,771.24,124.73,771.24,,,,,,ALCOHOL 70% 1 GALLON,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,5.03,5.03,33.1,,,,,,PRINTER LEXMARK C540X75G WASTE BOTTLE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,5.88,2.31,20.91,,,,,,TEST DART (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],314.3,235.73,235.73,17.05,14.09,91.91,,,,,,TUBE SET AUXILIARY WATER CHANNEL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],137.9,103.43,103.43,14.81,14.81,137.9,,,,,,INFLUENZA A & B KIT CLIA (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,6.58,5.44,96,,,,,,SHEET DRAW (SUB) do not use,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82247,Lab analysis to measure the total bilirubin level [HCPCS 82247],118.1,88.58,88.58,5.11,4.22,50.4,,,,,,TAPE CASTING 3 (DRK BLUE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],118.1,88.58,88.58,5.11,4.22,71.8,,,,,,TAPE CASTING 2 (PURPLE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,0,16.18,45.86,,,,,,GLOVES NITRILE (SMALL) STEEL BLUE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,30.08,30.08,290.1,,,,,,GLOVES NITRILE (MED) STEEL BLUE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,0,19.16,56.63,,,,,,GLOVES NITRILE (LG) STEEL BLUE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82397,Lab analysis to identify toxic levels of substances using chemiluminescent technique (light and chemical reaction) [HCPCS 82397],232.7,174.53,174.53,14.35,14.35,14.35,,,,,,GLOVES NITRILE (X-LG) SILVER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,4.42,4.42,42.84,,,,,,LABEL PREVENTIVE MAINTENANCE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,6.62,5.81,65.1,,,,,,MASK BLUE EAR LOOP PROCEDURE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,0,11.55,98.31,,,,,,FILTER ASSEMBLY BERKELEY SUCTION,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,5.26,4.35,81.23,,,,,,CONNECTION HOSE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82575,Lab analysis to measure the creatinine clearance in urine and blood specimens to test for kidney function [HCPCS 82575],131.3,98.48,98.48,9.62,9.62,15.68,,,,,,SAFE TOUCH COLLECTION SYSTEM,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,39.13,32.34,465.3,,,,,,KIT FLU A+B QUICKVUE QUIDEL (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],480.7,360.53,360.53,28.4,28.4,180.6,,,,,,TEGADERM TRANSPARENT FILM,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82677,Lab analysis to measure the estriol (hormone) level [HCPCS 82677],167.6,125.7,125.7,24.58,20.31,40.09,,,,,,MICROSCOPE SLIDES 1/2 GROSS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,13.85,11.45,112.4,,,,,,PITCHER GREY,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],243.7,182.78,182.78,14.94,14.94,192.28,,,,,,SUPER RAPID BIOLOGICAL INDICATOR,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82785,Lab analysis to measure the IgE (immune system protein) level [HCPCS 82785],135.7,101.78,101.78,16.73,16.51,56.85,,,,,,GREEN THERA-BAND 50yd (PERFORMANCE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,3.99,3.99,48.28,,,,,,ROLYAN AQUAPLAST-T WATER COLORS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,13.08,10.81,66.12,,,,,,BOOK PHONE MESSAGE SPIRAL (OD),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82952,Lab analysis to measure blood glucose (sugar) tolerance (each additional specimens beyond 3 specimens) [HCPCS 82952],38.7,29.03,29.03,3.98,3.98,38.7,,,,,,NEEDLE 18G1 (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,7.05,2.66,8.7,,,,,,PRINTER XEROX BLACK TONER 106R01047,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,18.89,16.1,220.5,,,,,,SHEET PROTECTOR 100/BX NON-GLARE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",399.1,299.33,299.33,18.83,18.83,178.6,,,,,,PRINTER HP Q49A BLACK (REMAN) TONER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,68.46,56.58,188.42,,,,,,CLOTH MICROFIBER DISPOSABLE (MEDLINE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,9.87,8.16,104.31,,,,,,VACU 5ML RED TOP,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,11.72,11.58,453.2,,,,,,POUCH DUAL SELF SEAL 7.5 X 13 (CARDINAL),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,6.57,5.43,33.59,,,,,,NITRAZINE PAPER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,8.88,7.34,38.68,,,,,,MOUTHWASH MEDICHOICE (SUB),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,11.76,9.72,190.22,,,,,,"TOWEL, (GREEN)",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,6.13,5.07,94.54,,,,,,RETRACTOR LARGE VAGINAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83655,Lab analysis to measure the lead level in blood specimen [HCPCS 83655],123.5,92.63,92.63,12.31,12.31,122.26,,,,,,NEEDLE HYPO 25X1 1/2 A BEVEL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,7.01,5,105.9,,,,,,GLOVES LG-SINGLE LATEX FREE (SUB),,0290,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,6.81,5.63,72.8,,,,,,FORM SKILLED NURSING VISIT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,39.91,32.98,268.8,,,,,,MARYLAND INSERT FORCEPS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,41.96,41.96,133.85,,,,,,ALCOHOL ISOPROPYL 70% 16OZ,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84030,"Lab analysis to measure the phenylalanine, PKU (amino acid) level in blood specimen [HCPCS 84030]",102.6,76.95,76.95,5.59,4.62,77.09,,,,,,SALT EPSON 16OZ(MEDLINE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,4.82,4.75,40.9,,,,,,MASK MEDC CHILD'S DINOSAUR(discopervendor),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],144.5,108.38,108.38,21.2,18.12,87.86,,,,,,"SYRINGE, 10 CC(SUB)",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84145,Lab analysis to measure the procalcitonin (hormone) level in serum or plasma specimen [HCPCS 84145],398.1,298.58,298.58,27.66,27.66,265.89,,,,,,TAPE INSTRUMENT MARKING (WHITE) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,19.7,19.44,112.66,,,,,,TAPE INST. MARKING (ROYAL BLUE) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,0,15.27,36.5,,,,,,TAPE INST. MARKING (KELLY GREEN) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,3.73,3.73,46.16,,,,,,TAPE INST. MARKING (RED) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84166,Lab analysis to measure the amount of protein in body fluid specimen [HCPCS 84166],233.8,175.35,175.35,18.13,17.83,229.12,,,,,,TAPE INST. MARKING (YELLOW) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84270,Lab analysis to measure the sex hormone binding globulin (protein) level in serum specimen [HCPCS 84270],240.4,180.3,180.3,22.08,22.08,180.6,,,,,,TAPE INST. MARKING (PURPLE) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84402,Lab analysis to measure free testosterone (hormone) level in serum specimen [HCPCS 84402],148.9,111.68,111.68,25.88,25.55,148.9,,,,,,TAPE INST. MARKING (ORANGE) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,26.23,25.9,240.4,,,,,,TAPE INST. MARKING (BLACK) 1/4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,9.17,7.58,134.6,,,,,,SENSOR MASIMO LNCS SpO2 (ER MASIMO),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,17.07,14.11,134.34,,,,,,PRINTER CANON 104 BLK TONER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,5.26,4.35,39.58,,,,,,MANUAL PROVIDER ACLS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",65.1,48.83,48.83,5.38,5.38,38.07,,,,,,DIALYZER OPTIFLUX 200NRe,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,5.83,5.83,44.1,,,,,,BLOODLINES COMBISET,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,14.41,14.41,153.94,,,,,,ACID BATH(55gdrum) 2K 2.5CAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",233.8,175.35,175.35,17.22,17.22,200.91,,,,,,ACID BATH 2K 3.0CAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,12.67,9.87,141.2,,,,,,ACID BATH 2K 2.0CAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84512,Lab analysis to identify troponin (protein) in plasma specimen [HCPCS 84512],174.2,130.65,130.65,10.26,10.26,73,,,,,,ACID BATH 2K 3.5CAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,4.6,4.54,50.4,,,,,,ACID BATH 3K 3.0CAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,21.15,17.05,191.3,,,,,,ACID BATH 3K 2.5CAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,15.29,12.64,85.85,,,,,,NATURALYTE BICARB DRY MIX,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,7.65,7.65,55.26,,,,,,NATURALYTE BICARB DRY MIX (CASE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],44.1,33.08,33.08,2.41,2.41,10,,,,,,OPTIFLUX DIALIZER 180NRE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],12.2,9.15,9.15,2.41,2.41,10,,,,,,TOURNIQUET(STRETCH),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.9,6,88.2,,,,,,COVER THERMOMETER (TEMPORAL CAPS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,6.57,5.43,37.5,,,,,,FILTER DIASAFE PLUS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,10.35,8.55,182.7,,,,,,HEMACLIP BLOODLINE CONNECTOR CLIP,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,4.36,3.6,69.6,,,,,,CHLORINE ULTRA 0.2PPM-1,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,4.34,3.56,42,,,,,,WATER HARDNESS TEST STRIPS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,2.75,2.7,54.33,,,,,,OPTIFLUX DIALIZER 160NRE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,6.11,6.03,69.6,,,,,,PRINTER HP 226X BLACK CARTRIDGE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,12.29,12.29,258.33,,,,,,CT MIXING CUP (32OZ.),,0270,,5.7,4.275,4.275
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86060,Lab analysis to identify strep throat antibody [HCPCS 86060],48.6,36.45,36.45,7.42,7.42,20.33,,,,,,CT BARRIUM (ORANGE VANILLA),,0270,,12.79,9.5925,9.5925
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,5.26,5.26,76.2,,,,,,CT BARRIUM (BANANA SMOOTHIE),,0270,,12.79,9.5925,9.5925
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,12.2,12.2,112.96,,,,,,CT BARRIUM (BERRY SMOOTHIE),,0270,,12.79,9.5925,9.5925
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,18.22,18.22,199.4,,,,,,CT BARRIUM (MOCHACCINO),,0270,,12.79,9.5925,9.5925
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,12.25,12.25,187.04,,,,,,CD-R 80 MIN 700MB (X-RAY),,0270,,5,3.75,3.75
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86308,Lab analysis to screen for mononucleosis (mono) [HCPCS 86308],53,39.75,39.75,5.26,5.26,30.95,,,,,,DISK-O-TAPE CD PAPER WITH WINDOW AND FLIP,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86335,Lab analysis by immunologic analysis technique on body fluid (other fluids with concentration) [HCPCS 86335],155.5,116.63,116.63,29.83,29.83,102.82,,,,,,DVD PRINTING,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86336,Lab analysis to measure the amount of reproductive organ horomone (inhibin A) [HCPCS 86336],283.4,212.55,212.55,15.85,13.1,25.85,,,,,,FILM 10X12,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,14.79,14.79,121.3,,,,,,SUPER SANI WIPES (INDIVIDUAL),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,5.76,5.76,186.4,,,,,,GOWN PATIENT (STANDARD TEXTILE) X-RAY,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,4.34,4.34,61.8,,,,,,LABEL PRINTER (NANOSONICS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86695,"Lab analysis to identify antibodies to Herpes simplex virus, type 1 [HCPCS 86695]",194.1,145.58,145.58,13.41,13.41,58.37,,,,,,PROBE CLEAN COVERS (NANOSONICS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86696,"Lab analysis to identify antibodies to Herpes simplex virus, type 2 [HCPCS 86696]",413.5,310.13,310.13,19.67,19.67,254.75,,,,,,INDICATOR CHEMICAL (NANOSONICS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,13.94,11.52,121.3,,,,,,DISK-O-TAPE DVD,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86765,Lab analysis to identify antibodies to Rubeola (measles virus) [HCPCS 86765],169.8,127.35,127.35,13.09,10.82,53.63,,,,,,DISK-O-TAPE BLACK THERMAL PRINTING,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,42.13,16.62,74.01,,,,,,JACKET BLUE LARGE (SURGERY),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86787,Lab analysis to identify antibodies to varicella-zoster virus (chicken pox) [HCPCS 86787],148.9,111.68,111.68,13.09,10.82,90.53,,,,,,JACKET WHITE MEDIUM (SURGERY),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86800,Lab analysis to identify antibodies to thyroglobulin (thyroid protein) [HCPCS 86800],92.7,69.53,69.53,16.17,16.17,16.17,,,,,,JACKET WHITE LARGE (SURGERY),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,57.3,6.74,92.02,,,,,,SCRUB AVAGARD 16OZ,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,4.02,2.99,62.24,,,,,,19MMX25CM SIGMOIDOSCOPE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,4.02,2.99,48.11,,,,,,BULB INSUFFLATION RECTAL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86906,Lab blood analysis for Rh phenotyping to confirm the Rh antibody [HCPCS 86906],390.3,292.73,292.73,6.51,6.51,228.22,,,,,,TRANSFORMER W/CORD,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,144.95,11.93,144.95,,,,,,FIBER OPTIC LIGHT CORD FOR OR,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,10.49,9.2,112.32,,,,,,INDICATOR STRIP (3M),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],54.4,40.8,40.8,9.6,9.6,22.79,,,,,,ENVELOPE ATTEST LOAD LIST (3M),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,8.76,7.24,496.86,,,,,,LABEL STERILIZATION(BLACK),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,9.62,9.38,86.39,,,,,,STRIPS TEST (RAPICIDE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,8.22,6.79,100.4,,,,,,LABEL PRECUT PROPOFOL 10MG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,6.74,5.57,65.1,,,,,,LABEL PRECUT MIDAZOLAM 1MG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,8.2,2.84,108.1,,,,,,LABEL PRECUT BENADRYL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,8.23,6.8,52.43,,,,,,LABEL PRECUT DEXAMETHASONE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87106,Lab analysis of fungal culture to identify yeast [HCPCS 87106],152.2,114.15,114.15,0,8.67,29.64,,,,,,LABEL PRECUT ONDANSETRON 2MG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],56.8,42.6,42.6,9.05,8.9,23.8,,,,,,LABEL PRECUT OXYTOCIN 10 UNITS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,8.8,7.27,172,,,,,,LABEL PRECUT ROCURONIUM 10MG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,4.34,4.29,39.3,,,,,,LABEL PRECUT SUCCINYCHOLINE 20MG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],56.8,42.6,42.6,18.27,12.41,29.8,,,,,,LABEL PRECUT VECURONIUM 1MG,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87254,Lab analysis of isolated viruses by centrifuge enhanced method [HCPCS 87254],419,314.25,314.25,19.88,19.88,254.75,,,,,,LABEL PRECUT DILAUDID,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87328,Lab analysis by immunoassay (ELISA) to identify cryptosporidium (parasite) [HCPCS 87328],136.8,102.6,102.6,14.05,11.61,22.91,,,,,,LABEL PRECUT FENTANYL 50mcg,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,14.36,8.17,155.5,,,,,,LABEL PRECUT NARCAN,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,14.13,11.68,116.85,,,,,,INDICATOR TEMPERATURE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,45.23,37.79,110.3,,,,,,STIMULATOR NERVE SUNSTIM PLUS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],211.7,158.78,158.78,12.17,11.89,22.79,,,,,,CHARGER VENT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,17.09,14.12,74.6,,,,,,PRINTER TONER BLACK (FAXPHONE) CANON,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",342.7,257.03,257.03,12.17,11.91,22.84,,,,,,LAMP HALOGEN OTOSCOPE(CLINIC),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,35.67,29.48,155.5,,,,,,REMOTE (TV),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],282.3,211.73,211.73,37.89,31.31,118.27,,,,,,HEAD OTOSCOPE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,35.67,29.48,155.5,,,,,,HEAD OPTHALMASCOPE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,21.42,4.29,35.67,,,,,,LAMP OPTHALMOSCOPE (CLINIC),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,71.35,58.97,116.37,,,,,,BATTERY LI-ION ACCUTOR PLUS VITAL SIGNS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,FILTER BACTERIA 1/8 PIPE TO BARB 3/PK,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,35.67,29.48,105,,,,,,THERMOMETER FRIDGE/FREEZE (FISHER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,44.38,40.24,406.9,,,,,,BATTERY OPHTHALMOSCOPE 3.5V WELCH ALLEN,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,88108,Lab examination of specimen by the conentration technique to diagnose disease [HCPCS 88108],33.1,24.83,24.83,38.85,13.86,38.85,,,,,,CABLE ECG 5 LEAD (MINDRAY),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,21.42,4.29,27.04,,,,,,CABLE ECG 3 LEAD (MINDRAY),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,24.19,13.86,24.19,,,,,,CABLE MASIMO LNCS SpO2 (ER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,38.85,20.12,77.89,,,,,,CARTRIDGE HP 62XL TRI-COLOR,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,92950,Heart and lungs restart (attempt) [HCPCS 92950],695.8,521.85,521.85,200.7,71.63,200.7,,,,,,CARTRIDGE HP 62XL BLACK,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,94.53,6.15,4344.87,,,,,,WASHCLOTH WHITE (DIETARY) 12X12,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",1427.8,1070.85,1070.85,350.85,350.85,944.09,,,,,,PAPER LETTER SIZE (TURQUOISE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,0,166.13,1092.27,,,,,,ELEMENT HEATING,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,64.7,16.49,98.36,,,,,,FLOOR FINISH (WAX) TOUGH GUY,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,98.36,19.15,448.97,,,,,,FLOOR STRIPPER (TOUGH GUY),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,416.66,28.6,1161.38,,,,,,PAPER TOWEL MULTI-FOLD (WHITE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,74.88,16.26,2475.42,,,,,,TOILET TISSUE PAPER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,344.79,68.61,524.17,,,,,,PAPER TOWEL ROLL (WHITE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,51.73,20.72,3197.1,,,,,,BUFFING PAD 20 (RED),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,0,34.19,143.78,,,,,,INTERCON FRESH AND CLEAN 4 GALLON,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96368,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (concurrent with another infusion) [HCPCS 96368]",92.7,69.53,69.53,0,38.81,108.8,,,,,,HAND SANITIZER W/ALOE 1ML (GOJO PUREL),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,127.2,4.51,1156.79,,,,,,SOAP ANTIBACTERIAL 800ML,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,371.48,29.4,2785.69,,,,,,BUFFING PAD 17 (BLACK),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,44.02,12.56,48.28,,,,,,GOWN PATIENT (MEDLINE) OSFA,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,23.92,10.24,44.01,,,,,,TOWEL WHITE (REGULAR SIZE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,132.04,40.84,136.8,,,,,,PAPER TOWEL ROLL,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],122.5,91.88,91.88,143.78,40.84,143.78,,,,,,PAPER TOWEL ROLL (TOUCHFREE DISPENSER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,98.36,23.51,98.36,,,,,,DISPENSER SOAP FOAM (TOUCHFREE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,428.4,140.59,428.4,,,,,,SOAP( no longer availalbe per vendor)FOAM (1200ML LAVENDER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],365,273.75,273.75,0,140.59,241.75,,,,,,HAND SANITIZER FOAM,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,154.11,40.84,154.11,,,,,,BLANKET BABY (KUDDLE-UP FOOTPRINT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,20.78,10.32,28.14,,,,,,LAUNDRY SOFTNER (NU-SOFT) 5 GAL.,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,146.36,35.11,337.46,,,,,,LAUNDRY DETERGENT (LD-3500) 5 GAL.,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,299.06,70.45,319.43,,,,,,BLANKET (MEDLINE) NATURAL COLOR 74X108,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,62.92,39.1,434.06,,,,,,SHEETS FLAT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,62.92,61.48,2109.82,,,,,,SHEETS FITTED,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,62.92,50,3116.59,,,,,,PILLOW CASES (REUSABLE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,1098.7,62.92,1098.7,,,,,,DUST MOP FRAME (5X18),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,0,2.42,250.2,,,,,,DUST MOP HANDLE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,0,5.83,3301.98,,,,,,MATTRESS PAD,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,0,7.4,19.63,,,,,,BLANKET BABY (THERMAL) MINT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,13.03,3.22,2266.54,,,,,,GOWN INFANT 0-6 MONTH,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0171,Adrenalin epinephrine inject [HCPCS J0171],2.5,1.88,1.88,0,0.8,1.67,,,,,,"PANT PATIENT, BLUE (MEDLINE)",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0290,Ampicillin 500 mg inj [HCPCS J0290],12.5,9.38,9.38,25,1.19,25,,,,,,GOWN PATIENT LARGE (NO CLIPS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0330,Succinycholine chloride inj [HCPCS J0330],3.95,2.96,2.96,3.04,1.74,3.04,,,,,,MATTRESS PAD 36X80 (STANDARD TEXTILE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],31.47,23.6,23.6,0,15.1,23.42,,,,,,LAUNDRY BLEACH 5 GAL.,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,14.67,5.5,14.67,,,,,,WASHCLOTH WHITE (LAUNDRY) 11X11,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,7.34,0.68,2868.2,,,,,,BLANKET BABY (THERMAL) WHITE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,0,13.53,65.14,,,,,,SOAP PINK (1000ML),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,2.93,0.11,332.88,,,,,,MOP BUCKET WRINGER (RUBBERMAID),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,0,2.1,2819.66,,,,,,BLANKET WHITE (ER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J1265,Dopamine injection [HCPCS J1265],3.89,2.92,2.92,4.56,1.71,4.56,,,,,,GOWN TIGER SNAP (X-SMALL),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J1650,Inj enoxaparin sodium [HCPCS J1650],14.44,10.83,10.83,0.86,0.47,8.78,,,,,,GOWN TOP TIGER (SMALL),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,20.27,5.5,1162.88,,,,,,PAJAMA PANT TIGER (SMALL),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0,0.73,808.23,,,,,,GOWN TOP TIGER (MEDIUM),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,29.34,7.08,29.34,,,,,,PAJAMA PANT TIGER (MEDIUM),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,29.34,7.8,30.4,,,,,,BLANKET BABY (CHICK PRINT),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,14.67,5.5,14.67,,,,,,PAD WHITE THIN LIGHT DUTY,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,29.34,11,29.34,,,,,,LAUNDRY DE-IRON PLUS 5 GAL.,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,14.67,0.95,3583.7,,,,,,LAUNDRY SO-SOFT (5 GAL),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,16.28,1.72,16.28,,,,,,BLANKET CHEVRON 70X90,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,29.34,2.81,811.33,,,,,,SHEETS CONTOUR (BLUE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,29.34,0.55,29.34,,,,,,SHEETS FLAT (BLUE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,34.14,5.49,347.63,,,,,,PILLOWCASE (BLUE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J3030,Sumatriptan succinate / 6 mg [HCPCS J3030],212.5,159.38,159.38,0,87.42,179.73,,,,,,BUFFING PAD 17 (RED),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,0,5.5,19.14,,,,,,BUFFING PAD 17 (WHITE),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J3410,Hydroxyzine hcl injection [HCPCS J3410],33.38,25.04,25.04,0,20.29,20.29,,,,,,CLEANER CARPET (ROBBIES),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,23.47,1.66,23.47,,,,,,MOP HEADS DISPOSABLE (MICROFIBER),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,23.48,1.76,23.48,,,,,,PAPER COLORED XEROX (TAN),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,0.81,0.02,4433.9,,,,,,PAPER COLORED XEROX (AQUA),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J7510,Prednisolone oral per 5 mg [HCPCS J7510],10.36,7.77,7.77,8.4,2.49,8.81,,,,,,SORTER PLASTIC PENDAFLEX (A-Z),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,0,2.4,4.25,,,,,,CARTRIDGE LEXMARK 521 BLACK TONER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,598.59,167.53,728.8,,,,,,"SUTURE , 4-0 DEXON II 9331-31",,0272,,286,214.5,214.5
AMERIGROUP INSURANCE COMPANY - Medicaid,Hospital,Institutional,Outpatient,S0171,Bumetanide 0.5 mg [HCPCS S0171],12.5,9.38,9.38,0,5.75,9.6,,,,,,SLING OBTRYX II CURVED SINGLE UNIT,,0278,,"1,501.5",1126.125,1126.125
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1721,1290.75,1290.75,0,1305.45,1305.45,,,,,,DIVIDER TABS 1-31,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",310.8,233.1,233.1,0,95.48,95.48,,,,,,"TAPE,DYMO 2-PACK 1 BLACK ON WHITE",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],194.3,145.73,145.73,0,73.93,98.64,,,,,,BANDAGE TUBULAR NET SIZE 1,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Institutional,Outpatient,T1015,Clinic service [HCPCS T1015],105.91,79.43,79.43,245.75,240.69,245.75,,,,,,BANDAGE TUBULAR NET SIZE 2,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,0,4.8,352,,,,,,BANDAGE TUBULAR NET SIZE 3,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,851,Anesthesia provided during tying or incision of fallopian tubes using an endoscope [HCPCS 00851],139,104.25,104.25,233.81,5.72,268.49,,,,,,BLADE LARYNGOSCOPE SZ 3,,0272,,124.02,93.015,93.015
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,952,Anesthesia provided during uterus examination using an endoscope [HCPCS 00952],139,104.25,104.25,184.83,5.79,184.83,,,,,,BLADE LARYNGOSCOPE MAC SZ 3.5,,0272,,206.7,155.025,155.025
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,1960,Anesthesia provided during vaginal delivery [HCPCS 01960],139,104.25,104.25,230.19,1.24,296.76,,,,,,POUCHES LAMINATING FELLOWS,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,1961,Anesthesia provided during cesarean delivery [HCPCS 01961],139,104.25,104.25,276.32,5.74,329.73,,,,,,LABEL ADDITIVE MED IV 2-3/8 x 1,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,245.34,3.36,245.34,,,,,,LABEL ID LINE I.V. OXYTOCIN 3,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,79.71,79.43,766.3,,,,,,"BIOFREEZE PROFESSIONAL, GEL 1G",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],7445.3,5583.98,5583.98,249.93,127.52,393.81,,,,,,"AQUASONIC, ULTRASOUND GEL, 5L",,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,58671,Blocking of uterine tubes by device with endoscope [HCPCS 58671],1591,1193.25,1193.25,275.86,275.86,577.59,,,,,,TEMPORAL EXERGEN THERMOMETER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,22.99,22.99,68.3,,,,,,THERABAND THIN YELLOW(25YDS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,583.91,583.91,1462.85,,,,,,THERABAND MEDIUM RED(25YDS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,673.72,138.2,1470.79,,,,,,THERABAND EXTRA HEAVY BLUE(25YDS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,0,45.56,141.93,,,,,,KIT METAL HALIDE HID BALLAST,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,8.98,8.98,23.86,,,,,,ENDOZIME (AW PLUS),,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,13.55,13.55,72.8,,,,,,BANDAGE TUBULAR NET SIZE 4,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,52.38,52.38,170.1,,,,,,THERABAND BLUE 50Y,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,52.53,52.53,206.9,,,,,,LABEL CLEAR SHIELD,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,90.59,81.71,178.67,,,,,,STRYKER TOWER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],371.6,278.7,278.7,122.95,122.95,194.97,,,,,,OLYMPUS ENDOSCOPY TOWER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,66.43,59.92,194.57,,,,,,VALLEY LAB FT10 1,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,105.38,95.05,222.03,,,,,,VALLEY LAB FT10 2,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,22.37,22.37,41.75,,,,,,VALLEY LAB BOVIE ENDO 3,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,39.55,39.55,134.08,,,,,,BAIR HUGGER,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,35.13,31.68,51.15,,,,,,ETHICON HARMONIC GENERATOR,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,45.48,45.48,91.29,,,,,,NOVASURE GENERATOR,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,114.76,114.76,176.55,,,,,,BERKELEY SUCTION MACHINE,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,60.51,59.99,274.04,,,,,,LUXTEC INTEGRA HEADLIGHT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,0,33.41,326.4,,,,,,VISUALUX 300 HEADLIGHT,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,80.36,77,101.03,,,,,,KENDALL SCD 1,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,38.82,38.82,44.36,,,,,,KENDALL SCD 2,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,99464,Newborn delivery and stabilization with physician attendance [HCPCS 99464],211.7,158.78,158.78,89.75,79.03,89.75,,,,,,KENDALL SCD PACU,,,,,,
AMERIGROUP INSURANCE COMPANY - Medicaid,Skilled Nursing Facility,Professional,Outpatient,T1015,Clinic service [HCPCS T1015],105.9,79.43,79.43,245.75,215.52,245.75,,,,,,PANDA WARMER,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Clinic,Institutional,Outpatient,J7307,Etonogestrel implant system [HCPCS J7307],628.5,471.38,471.38,1051.25,628.5,1051.25,,,,,,TRAY - C-SECTION,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Clinic,Institutional,Outpatient,T1015,Clinic service [HCPCS T1015],105.91,79.43,79.43,240.69,240.69,245.75,,,,,,TRAY - MAJOR,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,0,1.28,46.3,,,,,,TRAY - MINOR,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Clinic,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,0,5.3,5.3,,,,,,TRAY - LAPAROSCOPIC,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Clinic,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",5.3,3.98,3.98,0,5.3,5.3,,,,,,TRAY - HYSTERECTOMY ABDOMINAL,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,215.52,55.34,245.75,,,,,,TRAY - D & C,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Clinic,Professional,Outpatient,T1015,Clinic service [HCPCS T1015],105.9,79.43,79.43,215.52,215.52,245.75,,,,,,TRAY - TRACHEOSTOMY,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,0,55,125,,,,,,TRAY - HYSTEROSCOPY,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,25605,Broken forearm bone treatment at the wrist area on the thumb side of the wrist with manipulation (closed treatment) [HCPCS 25605],779.64,584.73,584.73,101.34,101.34,101.34,,,,,,TRAY - CYSTOSCOPY,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,16.21,2.44,580.94,,,,,,TRAY - RECTAL,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,831.66,137.3,1347.57,,,,,,TRAY - RECTAL LAP,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,694.65,73.48,1221.85,,,,,,TRAY - BOOKWALTER,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,70490,"Neck CT scan of the soft tissue of the neck without contrast to examine injury, foreign bodies, or tumors [HCPCS 70490]",1156.6,867.45,867.45,617.99,166.13,703.21,,,,,,CLAMP - HEMOSTAT,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,0,20.71,250.4,,,,,,CLAMP - KELLY,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,689.37,166.13,1107.72,,,,,,CLAMP - PEON,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,123.34,24.39,148.78,,,,,,CLAMP - KOCHER,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,73501,Hip x-ray of hip with pelvis (single view) [HCPCS 73501],225,168.75,168.75,0,49.24,127.42,,,,,,CLAMP - TONSIL,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,0,56.37,178.99,,,,,,CLAMP - RIGHT ANGLE,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",421.2,315.9,315.9,421.2,166.13,421.2,,,,,,CLAMP - ALLIS REGULAR,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,166.13,137.3,529.3,,,,,,CLAMP - LAHEY,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,8.6,8.49,161,,,,,,CLAMP - MOSQUITO,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.73,8.87,355.2,,,,,,CAMERA/LIGHTCORD,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,182.52,43.35,182.52,,,,,,RETRACTOR - DOUBLE-ENDED RICHARDSON,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,0,14.4,297.7,,,,,,"RETRACTOR - WEITLANER, SHARP",,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,63.16,63.16,518.42,,,,,,"RETRACTOR - WEITLANER, DULL",,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,9.42,9.42,73.71,,,,,,RETRACTOR - RAGNELL,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.22,2.66,76.2,,,,,,RETRACTOR - DEAVER,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,0,30.08,290.1,,,,,,RETRACTOR - SENNS,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,0,10.81,66.12,,,,,,RETRACTOR - GOULET,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,82952,Lab analysis to measure blood glucose (sugar) tolerance (each additional specimens beyond 3 specimens) [HCPCS 82952],38.7,29.03,29.03,0,3.98,38.7,,,,,,FILSHIE CLIP APPLIER LONG,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,17.07,14.11,134.34,,,,,,FILSHIE CLIP APPLIER SHORT,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,9.87,141.2,,,,,,SCISSOR - IRIS,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.9,6,88.2,,,,,,SCISSOR - TENOTOMY,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,4.36,3.6,69.6,,,,,,RECTAL PROBES,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,6.11,6.03,69.6,,,,,,CRYPT HOOK,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,42.13,16.62,74.01,,,,,,RETRACTOR - GELPI,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,86787,Lab analysis to identify antibodies to varicella-zoster virus (chicken pox) [HCPCS 86787],148.9,111.68,111.68,0,10.82,90.53,,,,,,RETRACTOR - SINGLE HANDLE RICHARDSON,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,8.76,7.24,496.86,,,,,,RETRACTOR - SKIN HOOKS,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,0,6.79,100.4,,,,,,CLAMP BABCOCK,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,5.57,5.57,65.1,,,,,,PICKUP - DEBAKEY,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,8.2,2.84,108.1,,,,,,PICKUP - ADSON SMOOTH,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,8.23,6.8,52.43,,,,,,PICKUP - ADSON WITH TEETH,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,0,7.27,172,,,,,,PICKUP - RUSSIAN,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,14.36,8.17,155.5,,,,,,PICKUP - FERRIS SMITH,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,37.79,37.79,110.3,,,,,,PICKUP - BONNIE,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,PICKUP - THUMB FORCEP WITH TEETH,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,70.13,29.48,105,,,,,,PICKUP - THUMB FORCEP WITHOUT TEETH,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,94.53,6.15,4344.87,,,,,,PICKUP - CUSHING WITH TEETH,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,49.25,16.26,2475.42,,,,,,TRAY - HYSTERECTOMY VAGINAL,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,25.6,4.51,1156.79,,,,,,RETRACTOR - BALFOUR,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,TRAY - MAYO STERILE,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,62.92,39.1,434.06,,,,,,BASIN - SINGLE,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,62.92,61.48,2109.82,,,,,,BASIN - DOUBLE,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,62.92,50,3116.59,,,,,,SCISSORS - MAYO STRAIGHT,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,62.92,62.92,1098.7,,,,,,SCISSORS - MAYO CURVED,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,0,5.83,3301.98,,,,,,SCISSORS - METZENBAUM,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2.15,0.68,2868.2,,,,,,SCISSORS - BANDAGE,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,16.75,2.1,2819.66,,,,,,SPECULUM - WEIGHTED LONG,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,J1630,Haloperidol injection [HCPCS J1630],25,18.75,18.75,16.75,1.08,29.34,,,,,,SPECULUM - WEIGHTED MEDIUM,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0,0.73,808.23,,,,,,SPECULUM - WEIGHTED SHORT,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,8.38,0.95,3583.7,,,,,,TENACULUM - SINGLE TOOTH,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,245.34,3.36,245.34,,,,,,CLAMP - SPONGE STICK,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,52.38,52.38,170.1,,,,,,CLAMP - ALLIS THIN SHANK,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,52.53,52.53,206.9,,,,,,CLAMP - PENNINGTON,,,,,,
"AMERIGROUP TEXAS, INC. - Medicaid",Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,39.55,39.55,134.08,,,,,,HARMONIC CORD,,,,,,
AMERIGROUP TX - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,TRAY - PLASTIC,,,,,,
AMERIGROUP TX - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,RETRACTOR - HILL FERGUSON,,,,,,
AMERIGROUP TX - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,RETRACTOR - PARKS,,,,,,
AMERIGROUP TX - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,SCOPE - 10MM 0 DEGREE,,,,,,
AMERIGROUP TX - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,114.08,70,166.6,,,,,,SCOPE - 10MM 30 DEGREE,,,,,,
AMERIGROUP TX - Commercial-PPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,SCOPE - 5MM 0 DEGREE,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,156.21,119.23,9860.3,,,,,,SCOPE - 5MM 30 DEGREE,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,22.51,16.31,81.11,,,,,,SCOPE - BARIATRIC 5MM 0 DEGREE,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,5253.83,3940.37,3940.37,686.73,13.56,1256.28,,,,,,SCOPE - BARIATRIC 5MM 30 DEGREE,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,153.2,51.31,199.63,,,,,,CLAMP - BOWEL,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,CLAMP - TOWEL CLAMP,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,NEEDLE HOLDER - LONG,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,NEEDLE HOLDER - MEDIUM,,,,,,
AMERIGROUP TX - Commercial-PPO,Hospital,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,NEEDLE HOLDER - SHORT,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,,Professional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],425.3,318.98,318.98,0,335.56,344.79,,,,,,RETRACTOR - ALMS,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,0,5.19,5.3,,,,,,RETRACTOR - FREER,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,,Professional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",301.4,226.05,226.05,0,132.62,231.48,,,,,,RETRACTOR - RIBBON,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],267,200.25,200.25,113.76,66.27,734.24,,,,,,RETRACTOR - NERVE HOOK,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,,Professional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],26.3,19.73,19.73,0,1.31,26.3,,,,,,NEEDLE HOLDER - HEANEY,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.69,2.44,580.94,,,,,,KNIFE HANDLE - #3,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],225,168.75,168.75,0,94.25,148.78,,,,,,KNIFE HANDLE - #4,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,9.5,8.87,355.2,,,,,,KNIFE HANDLE - #7,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,2.85,2.66,76.2,,,,,,CATHETHER TROCAR 16FR,,0272,,46.56,34.92,34.92
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,7.34,6.2,81.6,,,,,,CATHETER TROCAR 12FR,,0272,,31.65,23.7375,23.7375
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,6.2,5,105.9,,,,,,COLLAR BABY (BOUND TREE),,0270,,16.74,12.555,12.555
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,6.99,6,88.2,,,,,,MEGA TIP 0600M,,0272,,42.49,31.8675,31.8675
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,7.27,6.79,100.4,,,,,,MIRCON FILTER EXT SET 1.2,,0272,,11.51,8.6325,8.6325
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,7.26,2.84,108.1,,,,,,MIRCON FILTER EXT SET .22,,0272,,6.67,5.0025,5.0025
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,7.28,6.8,52.43,,,,,,MONSELS SOLUTION,,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,7.79,7.27,172,,,,,,PENCIL CAUTERY FORCE,,0272,,16.18,12.135,12.135
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,8.17,8.17,155.5,,,,,,TIP CAUTARY 0013,,0272,,14.56,10.92,10.92
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,46.18,45.82,378.9,,,,,,PEN (RED),,,,,,
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,31.58,29.48,105,,,,,,SPONGE PEANUT,,0270,,10.21,7.6575,7.6575
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,TIP CAUTERY 6.0 0016,,0272,,13.5,10.125,10.125
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,119.47,61.48,2109.82,,,,,,WRIST APPLICATION KINESIO,,0270,,13.24,9.93,9.93
AMERIHEALTH CARITAS LOUISIANA - Medicaid,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,0,0.95,3583.7,,,,,,FOOT APPLICATION KINESIO,,0270,,13.24,9.93,9.93
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,KNEE APPLICATION KINESIO,,0270,,13.24,9.93,9.93
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,11.69,8.87,355.2,,,,,,NECK APPLICATION KINESIO,,0270,,13.65,10.2375,10.2375
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,15.96,14.4,297.7,,,,,,BACK APPLICATION KINESIO,,0270,,13.24,9.93,9.93
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,11.76,9.42,73.71,,,,,,SHOULDER APPLICATION KINESIO,,0270,,13.24,9.93,9.93
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,3.1,1.89,53,,,,,,BAG PRESSURE (UNIFUSOR) 500CC,,0270,,27.8,20.85,20.85
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,5,5,105.9,,,,,,BLADE MILLER 2 DISPOSABLE (SOVEREIGN),,0272,,26.07,19.5525,19.5525
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,37.94,32.98,268.8,,,,,,STYLET 8 FR FLUORESCENT (SOVEREIGN),,0272,,9.45,7.0875,7.0875
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,9.87,9.87,141.2,,,,,,"TRAY, THORACENTESIS (CAREFUSION)",,0272,,51.7,38.775,38.775
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,6,6,88.2,,,,,,TIP CAUTARY (EXTRA LONG) 0014M,,0272,,13.23,9.9225,9.9225
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,4,3.6,69.6,,,,,,LIGASURE 5MM,,0272,,960.8,720.6,720.6
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,10.46,6.15,4344.87,,,,,,ENDOMETRIAL SAMPLERS,,,,,,
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,31.63,28.6,1161.38,,,,,,SHOE RELIEF PRESSURE,,,,,,
AMERIHEALTH CARITAS PENNSYLVANIA - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,50,50,3116.59,,,,,,MANIPULATOR UTERINE ZINNANTI 4.5,,0272,,47.28,35.46,35.46
AMGP GEORGIA MANAGED CARE CO INC - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,50,39.1,434.06,,,,,,MANIPULATOR UTERINE ADJUSTABLE,,0272,,38.12,28.59,28.59
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.89,5.3,61.31,,,,,,KIT CATHETER LUMEN 11.5 FR,,0272,,78.4,58.8,58.8
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,SHOE POST-OP OFF LOADING (SMALL),,0270,,56.69,42.5175,42.5175
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,SHOE POST-OP OFF LOADING (MEDIUM),,0270,,79.25,59.4375,59.4375
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,21.33,15.77,25,,,,,,SHOE POST-OP OFF LOADING (LARGE),,0270,,56.69,42.5175,42.5175
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,KNEE STABILIZER,,0270,,43.73,32.7975,32.7975
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,"SENSOR PEDI, (COVIDIEN) NELLCOR",,0272,,23.72,17.79,17.79
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,OUTDOOR TRACTION WITH WATERBAG,,,,,,
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,68.4,55.34,245.75,,,,,,"PULLEY, REACH N RANGE",,,,,,
ANTHEM - Commercial-PPO,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.35,14.35,372.57,,,,,,DRAIN CHEST SYS AQUA-SEAL,,0272,,89.07,66.8025,66.8025
ANTHEM - Commercial-PPO,Hospital,Institutional,Inpatient,203,Bronchitis or asthma without complications,5469.95,4102.46,4102.46,241.65,79.7,1453.4,,,,,,HAND REST COMFY DEVIATION ORTHOSIS,,,,,,
ANTHEM - Commercial-PPO,Hospital,Institutional,Inpatient,440,Disorders of pancreas except malignancy without complications,8042.43,6031.82,6031.82,0,2986.27,13236.43,,,,,,TRAY SAFE-T-CENTESIS 8FR,,0272,,99.17,74.3775,74.3775
ANTHEM - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,LIGASURE 2.5cm,,0272,,334.75,251.0625,251.0625
ANTHEM - Commercial-PPO,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,WALKER STABILIZER (RIGHT),,,,,,
ANTHEM - Commercial-PPO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,COVER CONTOUR NECK,,,,,,
ANTHEM - Commercial-PPO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,BLADE SWITCH SCISSORS (CAREFUSION),,0272,,100.56,75.42,75.42
ANTHEM - Commercial-PPO,Hospital,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.35,14.35,372.57,,,,,,PATCH KEYHOLE PLUG ROUND 8CM,,0278,,188.76,141.57,141.57
ANTHEM BCBS - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,46.3,1.28,46.3,,,,,,INSOLE OFF LOADING SHOE (SMALL),,0270,,30.16,22.62,22.62
ANTHEM BCBS - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,72.8,13.55,72.8,,,,,,INSOLE OFF LOADING SHOE (MEDIUM),,0270,,30.16,22.62,22.62
ANTHEM BCBS - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,INSOLE OFF LOADING SHOE (LARGE),,0270,,30.16,22.62,22.62
ANTHEM BCBS - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,14091.06,10568.3,10568.3,692.2,251.24,692.2,,,,,,TRAY SAFE-T-CENTESIS 6FR,,0272,,87.66,65.745,65.745
ANTHEM BCBS - Commercial-PPO,Hospital,Institutional,Inpatient,842,Lymphoma & non-acute leukemia without complications,109.2,81.9,81.9,86.22,13.75,130.84,,,,,,SHOE DH OFFLOAD XLG (PT),,0270,,56.69,42.5175,42.5175
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,8.8,2.44,580.94,,,,,,SPLINT THUMB PROCARE,,0270,,37.26,27.945,27.945
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,104.9,20.71,250.4,,,,,,ALEXIS WOUND PROTECTOR (SMALL),,0272,,81.12,60.84,60.84
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,103.05,8.87,355.2,,,,,,ALEXIS WOUND PROTECTOR (MEDIUM),,0272,,81.12,60.84,60.84
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,27.28,5.81,65.1,,,,,,ALEXIS WOUND PROTECTOR (LARGE),,0272,,113.88,85.41,85.41
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,30.49,5.63,72.8,,,,,,ALEXIS WOUND PROTECTOR (X-LARGE),,0272,,138.84,104.13,104.13
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,59.14,9.87,141.2,,,,,,EPIX LAPA GRASPER 5MM X 35CM,,0272,,82.35,61.7625,61.7625
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,36.96,6,88.2,,,,,,EPIX LAPA GRASPER 5MM X 45CM,,0272,,82.35,61.7625,61.7625
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,51.3,6.15,4344.87,,,,,,GELPOINT ADVANCE ACCESS PLATFORM,,0272,,682.5,511.875,511.875
ANTHEM CA - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,392.26,62.92,1098.7,,,,,,GELPORT 120MM,,0272,,682.5,511.875,511.875
APWU HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,300.05,70.45,319.43,,,,,,CATHETER CHOLANGIOGRAPHY,,0272,,106.08,79.56,79.56
APWU HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,315.01,107.28,315.01,,,,,,SUTURE 4-0 MAXON (8886614331),,0272,,27.28,20.46,20.46
APWU HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,SUTURE 2-0 MAXON (88866269-51),,0272,,17.16,12.87,12.87
APWU HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,140.22,8.87,355.2,,,,,,KNEE PADS (LARGE),,,,,,
APWU HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,84.87,11.25,148.9,,,,,,ELECTRODE(MONICA) FETAL MONITORING,,0270,,71.28,53.46,53.46
APWU HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,15.11,2.31,20.91,,,,,,TUBE SUMP WEIGHTED LONG ANDERSON AN20,,0272,,118.01,88.5075,88.5075
APWU HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,55.35,4.35,81.23,,,,,,NEEDLE BIOPSY TRUCUT 14GA x 6,,0272,,32.59,24.4425,24.4425
APWU HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,66.06,8.16,104.31,,,,,,DRAPE C-ARM (FULL COVERAGE),,,,,,
APWU HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,50.27,6,88.2,,,,,,CANNULA ADULT 5-40L/MIN,,0272,,12.98,9.735,9.735
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,41.67,1.28,46.3,,,,,,CANNULA SMALL PEDI-ADULT 5-40L/MIN,,0272,,12.98,9.735,9.735
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,65.84,13.55,72.8,,,,,,CIRCUIT HIGH FLOW (5-40L/MIN),,0272,,149.76,112.32,112.32
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,100.61,62.38,245.75,,,,,,"TRAY, UMBILICAL VESSEL",,0272,,107.07,80.3025,80.3025
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,150.67,70,166.6,,,,,,VISUALIZATION SYSTEM CLEARIFY (NEW),,0270,,91.29,68.4675,68.4675
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,19.95,2.44,580.94,,,,,,SCISSORS HOOK MONOPOLAR 5MM,,0272,,82.2,61.65,61.65
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,213.75,37.7,213.75,,,,,,DAKIN'S SOLUTION (16 OZ),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",53,39.75,39.75,33.1,5.03,33.1,,,,,,INSERT PRONEVIEW (LARGE),,0270,,45.75,34.3125,34.3125
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,275.6,30.08,290.1,,,,,,STOCKING AID & FLEXIBLE SOCK,,0270,,73.93,55.4475,55.4475
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],135.2,101.4,101.4,28.7,19.16,56.63,,,,,,SPLINT HAND POSITION ROYLAN,,0270,,66.52,49.89,49.89
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],50.8,38.1,38.1,43.1,18.04,43.1,,,,,,EXT. SET 8.5 W/PINCH CLAMP (CAREFUSION),,0272,,6.36,4.77,4.77
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],50.8,38.1,38.1,43.1,18.04,43.1,,,,,,NEEDLE BONE MARROW ( BD CAREFUSION),,0272,,24,18,18
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,30.9,4.42,42.84,,,,,,KIT CATHETER ELITE 12FR,,0270,,174.66,130.995,130.995
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,40.9,5.2,40.9,,,,,,IMPACT CURVED LG JAW,,0272,,"1,287.95",965.9625,965.9625
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,30.9,5.07,94.54,,,,,,CATHETER 8 FR DUAL LUMEN,,0272,,105.46,79.095,79.095
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],168.8,126.6,126.6,33.1,13.86,33.1,,,,,,CATHETER 13.5FR HIGH FLOW DUAL LUMEN,,0272,,121.68,91.26,91.26
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],53,39.75,39.75,40.9,4.75,40.9,,,,,,CATHETER 12FR HIGH PRESSURE TRIPLE LUMEN,,0272,,137.9,103.425,103.425
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],50.8,38.1,38.1,28.7,7.89,28.7,,,,,,SEPRAFILM 5X6 ADHESION BARRIER,,0272,,352.44,264.33,264.33
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],335.2,251.4,251.4,36.5,15.27,36.5,,,,,,PULLEY SHOULDER THERAPIST CHOICE,,0270,,20.93,15.6975,15.6975
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],50.8,38.1,38.1,41.9,18.48,44.1,,,,,,ARMBAND W/LABELS (CPSI),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,33.1,4.35,39.58,,,,,,ARMBAND JUV LABELS (CPSI),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,32.1,4.02,32.1,,,,,,ANTI-FOG OUT,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,148.86,45.82,378.9,,,,,,PAD STENO,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1389.2,1041.9,1041.9,1389.2,105.86,1389.2,,,,,,PHONE DISPOSABLE,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,13.93,6.13,13.93,,,,,,"WATER,DISTILLED GALLON",,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,1.44,0.63,1.44,,,,,,STRIP GLUCO TEST(NOVA BIO-MEDICAL),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Institutional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,9.09,4,9.09,,,,,,BIRTH CERTIFICATE (NEW),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",31.5,23.63,23.63,0,13.86,33.1,,,,,,"COVER, GURNEY 96X37 (WHITE)",,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],27.3,20.48,20.48,0,12.01,28.7,,,,,,SLEEVE BELLA LITE ARM,,0272,,75.07,56.3025,56.3025
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],41,30.75,30.75,0,18.04,43.1,,,,,,BEADS PARAFFIN (WINTERGREEN),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],41,30.75,30.75,0,18.04,43.1,,,,,,SHEET LAB MOUNT,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],29.4,22.05,22.05,0,12.94,30.9,,,,,,MOUSE WIRELESS OPTICAL,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],38.9,29.18,29.18,0,17.12,40.9,,,,,,KEYBOARD WIRELESS (INSIGNIA),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],29.4,22.05,22.05,0,12.94,30.9,,,,,,MOUSE OPTICAL USB (WIRED),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],31.5,23.63,23.63,0,13.86,33.1,,,,,,PHOTO CONTUDCTOR LEXMARK (E260),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],38.9,29.18,29.18,0,17.12,40.9,,,,,,TUBE TEST GLASS 5ML,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],27.3,20.48,20.48,0,12.01,28.7,,,,,,LOTION MASSAGE (PT),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],34.7,26.03,26.03,0,15.27,36.5,,,,,,MOUSE WIRELESS (LOGITECH),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],42,31.5,31.5,0,18.48,44.1,,,,,,TUBING SCD EXPRESS (OLD PUMPS),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",31.5,23.63,23.63,0,13.86,33.1,,,,,,TUBING SCD EXPRESS (NEW PUMPS),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],42,31.5,31.5,0,18.48,44.1,,,,,,ENVELOPE DISCHARGE (BLUE) 10X13,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],30.5,22.88,22.88,0,13.42,32.1,,,,,,RED THERAPY PUTTY (MEDIUM SOFT),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,2143.01,214.38,2255.8,,,,,,YELLOW THERAPY PUTTY (SOFT),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1323,992.25,992.25,0,582.12,1389.2,,,,,,KEYBOARD DESKTOP USB (WIRED),,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,0,8.17,13.93,,,,,,SHEET TRANSFER Z-SLIDER,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,0,4,8.64,,,,,,FOLDER CLASSIC LIGHT BLUE (HOME HEALTH),,,,,,
ASCEND TO WHOLENESS - Commercial-Mut Defined,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,62.18,36.98,63.97,,,,,,HANDLE MONOPOLAR W/O RATCHET,,,,,,
ASCEND TO WHOLENESS - Commercial-Mut Defined,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,193.88,134.02,193.88,,,,,,FLASH DRIVE 3.0 (32GB) AMAZON,,,,,,
ASCEND TO WHOLENESS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,93.83,91.42,145.6,,,,,,TISSUE FACIAL (AMAZON),,,,,,
ASCEND TO WHOLENESS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,108.68,70,166.6,,,,,,KEYBOARD WIRELESS (HP) K3500,,,,,,
ASCEND TO WHOLENESS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,464.4,1.93,464.4,,,,,,EARTIPS-PLANTRONICS,,,,,,
ASCEND TO WHOLENESS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,286.88,51.74,302.2,,,,,,CARDS PROCESS INDICATOR SERIES 2,,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,17.01,2.07,19.9,,,,,,FLASHLIGHT (NEBO 6525 SLYDE),,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,0,5.3,61.31,,,,,,BAG ZIPLOCK 2 GALLON,,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,0,5.19,5.3,,,,,,HOLDER COUNT SHEET FOR INSTRUMENT,,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,70,62.38,245.75,,,,,,TUMBLER 8OZ (DIETARY),,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,70,70,166.6,,,,,,TUMBLER 6OZ(DIETARY),,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0,0.08,6.58,,,,,,CLEANER AUTOCLAVE,,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,FACE SHIELD (DISPOSABLE),,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],26.3,19.73,19.73,0,1.31,26.3,,,,,,TRANSDUCER PROTECTOR,,,,,,
"ASRM, LLC - Commercial-PPO",,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,0,1.1,17.76,,,,,,BLOOD LEAK STRIPS EZ- CHEK,,,,,,
ASSURED BENEFITS ADMINISTRATORS - Commercial-PPO,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],225,168.75,168.75,0,27.4,191.25,,,,,,IV REPLACEMENT CAP,,,,,,
ASSURED BENEFITS ADMINISTRATORS - Commercial-PPO,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,0,24.39,148.78,,,,,,FISTULA(HENRYSCHEIN) NEEDLE 14GX1,,,,,,
ASSURED BENEFITS ADMINISTRATORS - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,0,61.48,2109.82,,,,,,NEEDLE(HENRYSCHEIN) FISTULA 15GX1 1/4,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,NEEDLE(HENRY SCHEIN) FISTULA 16GX1,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,70250,Skull bones x-ray (less than 4 views) [HCPCS 70250],225,168.75,168.75,0,166.13,166.13,,,,,,NEEDLE(HENRYSCHEIN) FISTULA 16GX1 1/4,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,0,137.3,1347.57,,,,,,NEEDLE FISTULA 17GX1 1/4,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,58.06,20.71,250.4,,,,,,GOWN YELLOW (LARGE),,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,0,272.21,1200.54,,,,,,GOWN YELLOW (X-LARGE),,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],225,168.75,168.75,58.06,4.45,148.78,,,,,,ADAPTOR MALE TO MALE LUER TO LUER,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,0,166.13,1107.72,,,,,,CAP BLOOD LINE RED/BLUE,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],98.2,73.65,73.65,78.21,41.14,166.13,,,,,,KIT RESIDUAL CHLORINE STRIPS 5BTL,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,0,561.23,2500,,,,,,KIT BICARB PH 6BTL,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,0,8.49,161,,,,,,CLAMPS BLUE,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.14,2.66,76.2,,,,,,DIALYZER REXEED 25SX WET,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,0,6.2,81.6,,,,,,REAGENT HARDNESS TABLET 5,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,9.87,141.2,,,,,,METER PHOENIX (DIALYSIS),,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,0,6,88.2,,,,,,REAGENT HARDNESS TABLET 6,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,0,3.6,69.6,,,,,,EXCHANGE BLOOD PUMP MOTOR AND GEAR 2008K,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,0,6.03,69.6,,,,,,EXCHANGE HYDRO CHAMBER,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,16.64,14.12,74.6,,,,,,FILTER PYROPEN,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,50.8,45.82,378.9,,,,,,SHIELD LONG REPLACEMENT,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,0,6.15,4344.87,,,,,,NEEDLE FISTULA 15GX1 (SUB),,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,NEEDLE(HENRYSCHEIN) FISTULA 15GX1 (SUB),,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,0,12.56,48.28,,,,,,LABELS CALIBRATED NOT IN USE,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,136.86,61.48,2109.82,,,,,,CLIP QUEASE EASE,,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,218.97,50,3116.59,,,,,,BULB VAGINAL SPECULA (WELCH ALLYN),,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,0,62.92,1098.7,,,,,,BATTERY MOBILE COMPUTER CART (55Ah),,,,,,
AZCH-COMPLETE CARE PLAN - Medicaid,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,0,7.08,29.34,,,,,,FILTER KIT EXHAUST VACUMM PUMP,,,,,,
"B H, INC. - Commercial-Mut Defined",Other Professional Setting,Institutional,Outpatient,300,Peripheral vascular disorders with complications,21336.11,16002.08,16002.08,0,174.72,174.72,,,,,,FILTER ACOUSTIC ECHO FILTER,,,,,,
"B H, INC. - Commercial-Mut Defined",Other Professional Setting,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,157.5,45.82,378.9,,,,,,"TRAYMAT, FLORENTINE LINEN",,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,CHEM-AQUA 16280 30 GAL,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.97,2.44,580.94,,,,,,CHEM-AQUA 52885,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,896.15,137.3,1347.57,,,,,,CHEM-AQUA 16280 5 GAL,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,748.52,73.48,1221.85,,,,,,CHEM-AQUA CA888 30 GAL,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,128.25,18.85,148.78,,,,,,CHEM-AQUA SULFITE-30GAL,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,128.25,33.08,182.07,,,,,,VIREX 256 DISINFECTANT CLEANER,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,91.77,8.49,161,,,,,,CREW TOILET BOWL CLEANER,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43.43,2.66,76.2,,,,,,LYSOL FOAMING DISINFECTANT,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,50.27,6,88.2,,,,,,LYSOL CRISP LINEN DISINFECTANT,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,21.38,5.43,37.5,,,,,,BLUE DOODLEBUG PAD,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,57.23,6.79,100.4,,,,,,COMET CLEANER LIQUID W/ BLEACH,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,0,2.84,108.1,,,,,,SPRAYAWAY STAINLESS STEEL CLEANER,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,98.04,7.27,172,,,,,,GLASS CLEANER (SPRAYWAY),,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,69.83,6.15,4344.87,,,,,,SNAPBACK SPRAY BUFF MAINTAINER,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,SPRAYWAY DUSTUP,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,202.35,68.61,524.17,,,,,,LINER TRASH CAN (WHITE) 40X48,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,44,20.72,3197.1,,,,,,LINER TRASH CAN (WHITE) 30X36,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,44.69,4.51,1156.79,,,,,,LINER TRASH CAN (RED) 30X36,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,341.32,29.4,2785.69,,,,,,LINER TRASH CAN (RED) 40X48,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,21.38,12.56,48.28,,,,,,TOILET SEAT BANDS,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,22.63,10.24,44.01,,,,,,FURNITURE POLISH (LEMON) 18OZ.,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,64.13,40.84,136.8,,,,,,LINER TRASH CAN (WHITE) 24X32,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,208.05,140.59,428.4,,,,,,LINER TRASH CAN (RED) 24X24,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],131.3,98.48,98.48,74.84,40.84,154.11,,,,,,MOP HEADS (MEDIUM) BLUE,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,533.58,62.92,1098.7,,,,,,DUST MOP 18,,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,17.31,5.83,3301.98,,,,,,DUST MITT (WAGNER),,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,0,52.53,206.9,,,,,,"MOPSTICK, PLASTIC",,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99226,Subsequent observation care (typically 35 minutes per day) [HCPCS 99226],285.4,214.05,214.05,98.08,98.08,98.08,,,,,,SPONGE SCRUBBER (YELLOW & GREEN),,,,,,
BANKERS LIFE AND CASUALTY - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,0,114.76,176.55,,,,,,CLOTH MICROFIBER (BLUE),,,,,,
BCBS OF ILLINOIS - Commercial-HMO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,MOP HEADS (LARGE) BLUE,,,,,,
BCBS OF ILLINOIS - Commercial-HMO,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,39.7,36.98,63.97,,,,,,FURNITURE POLISH 12.5OZ,,,,,,
BCBS OF ILLINOIS - Commercial-HMO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.58,62.38,245.75,,,,,,WAX CLARION 5GAL,,,,,,
BCBS OF ILLINOIS - Commercial-HMO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,500.48,15.26,797.02,,,,,,MOP HEADS WHITE FINISH (WAX),,,,,,
BCBS OF ILLINOIS - Commercial-HMO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,5253.83,3940.37,3940.37,13.56,13.56,1256.28,,,,,,CLEANER STRAIGHT-UP,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,77.92,70.45,319.43,,,,,,PAD MAROON SURFACE 14X20,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,PAD RED SQUARESCRUB 14X20,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,PAD WHITE SQUARE POLISH 14X20,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,204.1,156.33,346.97,,,,,,LINER SANITARY WAXED PAPER,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,21.33,15.77,25,,,,,,MOP HEADS (MEDIUM) GREEN,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,39.7,36.98,63.97,,,,,,SQUEEGEE BLADES FOR BLUE MACHINE,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,191.45,134.02,193.88,,,,,,DUST MOP BLUE 5X36,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,PAD SCOTCH BRIGHT SCRUBBING (GREEN),,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,SHAMPOO CARPET JET STREAM,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,COBWEB DUSTER (WAGNER),,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,CLIPS SUPER SANIPULL,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,15.78,14.35,372.57,,,,,,SMALL BLUE COMET BLEND WET MOP,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,KEYS BLANK (SARGENT),,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,E-Z SEAL SEALING SOLUTION- 4 HALF BOTTLE,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],26.3,19.73,19.73,1.31,1.31,26.3,,,,,,CARTRIDGE RED INK FOR POSTAGE MACHINE,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,NOVASURE DEVICE WITHOUT SOUND,,0270,,"1,647.1",1235.325,1235.325
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,93,Other disorders of nervous system without complications,365,273.75,273.75,282.79,97.24,1487.7,,,,,,ADVANCED NOVASURE DEVICE WITHOUT SOUND,,0272,,"1,458.17",1093.6275,1093.6275
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,115.04,15.26,797.02,,,,,,NEPRO,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,87.23,62.11,380.62,,,,,,JEVITY 1.2,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,313,Chest pain,1698.38,1273.79,1273.79,1434.85,120.51,1434.85,,,,,,SIMILAC BREAST FEEDING GIFT PACK,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,1314.26,119.23,9860.3,,,,,,SIMILAC ADVANCE 2OZ.,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,7848.97,5886.73,5886.73,1228.08,85.21,1228.08,,,,,,ENSURE,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,1811.75,114.13,1811.75,,,,,,ENSURE PLUS,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,605,"Trauma to the skin, subcut tiss & breast without major complications",244.8,183.6,183.6,610.63,127.96,1897.14,,,,,,GLUCERNA,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,639,Diabetes without complications,136.9,102.68,102.68,280.01,16.31,2312.51,,,,,,GLUCOSE WATER 5%,,,,,,
BCBS OF ILLINOIS - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,GLUCOSE WATER 10% 2290,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",31.5,23.63,23.63,33.1,13.86,33.1,,,,,,JEVITY,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],27.3,20.48,20.48,28.7,12.01,28.7,,,,,,NIPPLES PREMIE,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,82374,Lab analysis to measure the carbon dioxide (bicarbonate) level [HCPCS 82374],41,30.75,30.75,43.1,18.04,43.1,,,,,,NIPPLES REGULAR,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,82435,Lab analysis to measure the blood chloride level [HCPCS 82435],41,30.75,30.75,43.1,18.04,43.1,,,,,,PEDIALYTE 4 OZ BOTTLE,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],29.4,22.05,22.05,30.9,12.94,30.9,,,,,,SUPLENA W/CARBSTEADY,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],38.9,29.18,29.18,40.9,17.12,40.9,,,,,,WATER 1.0 LITER STERILE,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],29.4,22.05,22.05,30.9,12.94,30.9,,,,,,SIMILAC SENSITIVE 2OZ.,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],31.5,23.63,23.63,33.1,13.86,33.1,,,,,,PEDIASURE WITH FIBER,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],38.9,29.18,29.18,40.9,17.12,40.9,,,,,,GLUCERNA 1.2 CAL,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],27.3,20.48,20.48,28.7,12.01,28.7,,,,,,VALVE REPAIR KIT,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],34.7,26.03,26.03,36.5,15.27,36.5,,,,,,REAGENT 5 HARDNESS 500ML,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],42,31.5,31.5,44.1,18.48,44.1,,,,,,CHLORINE DPD #3R TABLET,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",31.5,23.63,23.63,33.1,13.86,33.1,,,,,,CHLORINE DPD #1R TABLET,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],42,31.5,31.5,44.1,18.48,44.1,,,,,,PAD MAMMO BREAST CUSHION,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],30.5,22.88,22.88,32.1,13.42,32.1,,,,,,NOVASURE CO2 CARTRIDGES,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,90999,Unlisted procedure for inpatient or outpatient dialysis [HCPCS 90999],1323,992.25,992.25,1389.2,582.12,1389.2,,,,,,Tyler Test Item 2,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,J0882,"Darbepoetin alfa, esrd use [HCPCS J0882]",13.93,10.45,10.45,13.93,8.17,13.93,,,,,,63739-0672-10 - ibuprofen 400 mg Tab [REEV],,0250,63739-0672-10,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part A",Skilled Nursing Facility,Professional,Outpatient,J2501,Paricalcitol [HCPCS J2501],9.09,6.82,6.82,8.64,4,8.64,,,,,,68084-0703-01 - ibuprofen 600 mg Tab [REEV],,0250,68084-0703-01,,,
BCBS OF NEW MEXI - Commercial-HMO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,168.11,119.23,9860.3,,,,,,50268-0430-15 - indomethacin 25 mg Cap [REEV],,0250,50268-0430-15,,,
BCBS OF NEW MEXI - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,77.92,70.45,319.43,,,,,,68084-0217-21 - irbesartan 150 mg Tab [REEV],,0250,68084-0217-21,,,
BCBS OF NEW MEXI - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,90937 HEMODIALYSIS COMMERCIAL INS CHARGE,90937,0821,,"1,389.2",1041.9,1041.9
BCBS OF NEW MEXI - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,90999 HEMODIALYSIS CHARGE,90999,0821,,"1,389.2",1041.9,1041.9
BCBS OF NEW MEXI - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,80069 RENAL FUNCTION CHARGE,80069,0300,,118.1,88.575,88.575
BCBS OF NEW MEXI - Commercial-PPO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,372.42,15.26,797.02,,,,,,82040 ALBUMIN CHARGE,82040,0300,,33.1,24.825,24.825
BCBS OF NEW MEXI - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,291.48,62.11,380.62,,,,,,62175-0128-37 - isosorbide mononitrate 30 mg ER Tab [REEV],,0250,62175-0128-37,,,
BCBS OF NEW MEXI - Commercial-PPO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,176.44,119.23,9860.3,,,,,,82310 CALCIUM CHARGE,82310,0300,,28.7,21.525,21.525
BCBS OF NEW MEXI - Commercial-PPO,Hospital,Institutional,Inpatient,864,Fever,165.4,124.05,124.05,131.7,87.23,344.13,,,,,,82374 C O 2 BICARBONATE CHARGE,82374,0300,,43.1,32.325,32.325
BCBS OF NEW MEXI - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,82435 CHLORIDE BLOOD CHARGE,82435,0300,,43.1,32.325,32.325
BCBS OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,77.58,70.45,319.43,,,,,,82465 CHOLESTEROL CHARGE,82465,0300,,30.9,23.175,23.175
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,0,61.63,100.1,,,,,,82565 CREATININE SERUM CHARGE,82565,0300,,40.9,30.675,30.675
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,82728 FERRITIN CHARGE,82728,0300,,66.2,49.65,49.65
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,11.9,1.28,46.3,,,,,,82947 GLUCOSE (BLOOD SUGAR) CHARGE,82947,0300,,46.3,34.725,34.725
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,15.77,15.77,25,,,,,,83540 IRON CHARGE,83540,0300,,32.1,24.075,24.075
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,83550 U I B C CHARGE,83550,0300,,43.1,32.325,32.325
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.14,13.55,72.8,,,,,,83615 LDH CHARGE,83615,0300,,30.9,23.175,23.175
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.58,62.38,245.75,,,,,,83970 PTH INTACT CHARGE,83970,0300,,201.9,151.425,151.425
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,113.59,70,166.6,,,,,,84075 ALK PHOSPHATE CHARGE,84075,0300,,33.1,24.825,24.825
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,84100 PHOSPHORUS SERUM CHARGE,84100,0300,,40.9,30.675,30.675
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,65.1,65.1,68.4,,,,,,84132 POTASSIUM CHARGE,84132,0300,,28.7,21.525,21.525
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,84155 PROTEIN TOTAL SERUM CHARGE,84155,0300,,36.5,27.375,27.375
BCBS OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,84295 SODIUM CHARGE,84295,0300,,44.1,33.075,33.075
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,103,Headaches without major complications,1572.2,1179.15,1179.15,70.13,44.95,787.11,,,,,,84450 SGOT CHARGE,84450,0300,,33.1,24.825,24.825
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,797.02,15.26,797.02,,,,,,84478 TRIGLYCERIDES CHARGE,84478,0300,,44.1,33.075,33.075
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,14091.06,10568.3,10568.3,355.29,251.24,692.2,,,,,,84520 B U N UREA NITROGEN CHARGE,84520,0300,,32.1,24.075,24.075
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,62.11,62.11,380.62,,,,,,85014 HEMATOCRIT CHARGE,85014,0300,,12.2,9.15,9.15
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,305,Hypertension without major complications,504.1,378.08,378.08,0,56.14,1006,,,,,,85018 HEMOGLOBIN CHARGE,85018,0300,,12.2,9.15,9.15
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,312,Syncope & collapse,366.5,274.88,274.88,118.11,118.11,1683.78,,,,,,85025 CBC CHARGE,85025,0300,,37.5,28.125,28.125
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,210.47,119.23,9860.3,,,,,,87340 HBSAG CHARGE,87340,0300,,50.8,38.1,38.1
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,345.22,114.13,1811.75,,,,,,36430 BLOOD ADMIN FEE CHARGE,A4750,0300,,12.2,9.15,9.15
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,601,Non-malignant breast disorders without complications,957.3,717.98,717.98,172.13,114.13,204.41,,,,,,ADMIN FEE-FLU VACCINE CHARGE,G0008,0771,,14.4,10.8,10.8
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,1728.61,106.96,3862,,,,,,ADMIN FEE-PNEUMOCOCCAL VACCINE CHARGE,G0009,0771,,4.5,3.375,3.375
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,639,Diabetes without complications,136.9,102.68,102.68,226.82,16.31,2312.51,,,,,,ADMIN FEE-HEP B VAC CHARGE,G0010,0771,,14.4,10.8,10.8
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,21.45,16.31,81.11,,,,,,50268-0452-15 - isosorbide mononitrate ER 60 mg Tab [REEV],,0250,50268-0452-15,,,
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,866,Viral illness without major complications,2386.03,1789.52,1789.52,0,415.75,829.47,,,,,,94620 PULMONARY STRESS TEST CHARGE,94620,0482,,373.8,280.35,280.35
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",9266.42,6949.82,6949.82,18.69,18.69,580.69,,,,,,00536-4087-06 - lactase Tab [REEV],,0250,00536-4087-06,,,
BCBS OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,83.12,51.31,199.63,,,,,,ABG RESTING AND POST EXE CHARGE,82803,0300,,293.3,219.975,219.975
BCBS OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,ABG STUDY CHARGE,82803,0300,,234.9,176.175,176.175
BCBS OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.58,62.38,245.75,,,,,,AEROSOL TREATMENT CHARGE,94640,0410,,83.8,62.85,62.85
BCBS OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,SVN SUBSEQUENT CHARGE,94640,0410,,83.8,62.85,62.85
BCBS OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,SVN TREATMENT/ NURSE CHARGE,94640,0410,,,,
BCBS OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,101.99,79.43,766.3,,,,,,68180-0602-07 - lamiVUDine 150 mg Tab [REEV],,0250,68180-0602-07,,,
BCBS OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,76.47,59.99,274.04,,,,,,OXYGEN TENT HOURLY CHARGE,,0270,,27.7,20.775,20.775
BCBS OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,100.6,77,101.03,,,,,,OXYGEN USAGE HOURLY CHARGE,,0270,,27.7,20.775,20.775
BCBS OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,44.17,38.82,44.36,,,,,,OXYGEN INITIAL SET UP CHARGE,,0270,,27.7,20.775,20.775
BCBS OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,5.3,4.51,1156.79,,,,,,00904-6352-61 - levofloxacin 500 mg Tab [REEV],,0250,00904-6352-61,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],230.5,172.88,172.88,80.15,80.15,262.94,,,,,,60687-0333-01 - lisinopril 20 mg Tab [REEV],,0250,60687-0333-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,47.35,35.11,337.46,,,,,,00904-5811-61 - lisinopril 5 mg Tab [REEV],,0250,00904-5811-61,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,77.92,70.45,319.43,,,,,,00456-3210-63 - memantine 10 mg Tab [REEV],,0250,00456-3210-63,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],65.1,48.83,48.83,65.1,65.1,236.48,,,,,,60687-0155-01 - metFORMIN 500 mg Tab [REEV],,0250,60687-0155-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,2.53,0.68,2868.2,,,,,,53489-0386-01 - minoxidil 2.5 mg Tab [REEV],,0250,53489-0386-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,1.29,1.29,348.28,,,,,,59762-5007-01 - misoprostol 100 mcg Tab [REEV],,0250,59762-5007-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,95.52,61.63,100.1,,,,,,50383-0565-10 - neomycin 500 mg Tab [REEV],,0250,50383-0565-10,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,59762-1004-01 - NIFEdipine 10 mg Cap [REEV],,0250,59762-1004-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,51079-0400-20 - NIFEdipine 30 mg ER Tab [REEV],,0250,51079-0400-20,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,51672-4001-05 - nortriptyline 10 mg Cap [REEV],,0250,51672-4001-05,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90621,Meningococcus lipoprotein vaccine for injection into muscle (2 or 3 dose schedule) [HCPCS 90621],365.7,274.28,274.28,196.74,196.74,196.74,,,,,,65862-0390-10 - ondansetron 4 mg Dis Tab [REEV],,0250,65862-0390-10,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,50268-0604-15 - nortriptyline 25 mg Cap [REEV],,0250,50268-0604-15,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,113.7,91.42,145.6,,,,,,66993-0068-80 - pantoprazole 40 mg Oral EC Tab [REEV],,0250,66993-0068-80,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,168.53,140.39,202.54,,,,,,68084-0044-01 - PARoxetine 10 mg Tab [REEV],,0250,68084-0044-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,0,8.98,23.86,,,,,,57237-0040-01 - Penicillin V Potassium 250 mg Tab [REEV],,0250,57237-0040-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,69367-0162-04 - phenazopyridine 100 mg Tab [REEV],,0250,69367-0162-04,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,11523-7234-04 - polyethylene glycol 3350 Oral Pwdr for Recon [REEV],,0250,11523-7234-04,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,114.08,70,166.6,,,,,,69543-0379-30 - potassium chloride 20 mEq Oral Pwdr [REEV],,0250,69543-0379-30,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,152.85,147.2,226.48,,,,,,68084-0360-09 - potassium chloride 20 mEq ER Tab [REEV],,0250,68084-0360-09,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,66758-0190-92 - potassium chloride 20 mEq ER Tab [REEV],,0250,66758-0190-92,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,51079-0542-20 - prochlorperazine 10 mg Tab [REEV],,0250,51079-0542-20,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J1030,Methylprednisolone 40 mg inj [HCPCS J1030],26.3,19.73,19.73,4.94,4.94,5.92,,,,,,60687-0338-01 - QUEtiapine 50 mg oral tablet [REEV],,0250,60687-0338-01,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,5.44,5.44,26.3,,,,,,"90750 Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use",90750,0521,,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],26.3,19.73,19.73,2.45,1.11,2.45,,,,,,00904-6082-61 - zolpidem 5 mg Tab [REEV],,0250,00904-6082-61,,,
BCBS OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,REEV MRI 3D Reconstruction,,,,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,74,Cranial & peripheral nerve disorders without major complications,21172.68,15879.51,15879.51,0,69.6,3586.14,,,,,,REEV US OB Greater Than 14 Weeks Multi,,,,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,93,Other disorders of nervous system without complications,365,273.75,273.75,1007.76,97.24,1487.7,,,,,,REEV US OB Detailed Addl Fetus,,,,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,103,Headaches without major complications,1572.2,1179.15,1179.15,152.9,44.95,787.11,,,,,,42023-0188-10 - neostigmine 0.5 mg/mL [REEV],J2710,0250,42023-0188-10,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,0,15.26,797.02,,,,,,60687-0138-01 - pyrazinamide 500 mg Tab [REEV],,0250,60687-0138-01,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,178,Respiratory infections & inflammations with complications,23123.75,17342.81,17342.81,3760.39,1906.72,3760.39,,,,,,60687-0281-01 - nortriptyline 10 mg Cap [REEV],,0250,60687-0281-01,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,14091.06,10568.3,10568.3,0,251.24,692.2,,,,,,68001-0187-05 - quinapril 20 mg Tab [REEV],,0250,68001-0187-05,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,11673.09,8754.82,8754.82,2052.29,128.55,4612.24,,,,,,60687-0343-01 - ramipril 5 mg Cap [REEV],,0250,60687-0343-01,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,203,Bronchitis or asthma without complications,5469.95,4102.46,4102.46,79.7,79.7,1453.4,,,,,,50458-0580-30 - rivaroxaban 10 mg Tab UD [REEV],,0250,50458-0580-30,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,65.22,62.11,380.62,,,,,,50458-0578-10 - rivaroxaban 15 mg Tab [REEV],,0250,50458-0578-10,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,305,Hypertension without major complications,504.1,378.08,378.08,0,56.14,1006,,,,,,60687-0242-01 - sertraline 50 mg Tab [REEV],,0250,60687-0242-01,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,312,Syncope & collapse,366.5,274.88,274.88,176.44,118.11,1683.78,,,,,,00006-0112-28 - sitaGLIPtin 50 mg oral tablet [REEV],,0250,00006-0112-28,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,391,"Esophagitis, gastroent & misc digest disorders with major complications",19666.17,14749.63,14749.63,87.23,87.23,10409.97,,,,,,51079-0979-20 - spironolactone 50 mg Tab [REEV],,0250,51079-0979-20,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,1489.43,119.23,9860.3,,,,,,REEV Vacutainer Butterfly 23g,,0272,,0,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,395,Other digestive system diagnoses without complications,14799.06,11099.3,11099.3,1406.51,127.96,1406.51,,,,,,BORN ON ARRIVAL SERVICE CHARGE,,0729,,160,120,120
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,443,"Disorders of liver except malig,cirr,alc hepa without complications",744.5,558.38,558.38,394.4,67.99,394.4,,,,,,IN-LABOR CARE ADDTL HOUR CHARGE,,0729,,562.3,421.725,421.725
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,547,Connective tissue disorders without complications,499.7,374.78,374.78,46.39,46.39,582.26,,,,,,IN-LABOR CARE 1 HOUR CHARGE,,0729,,55.2,41.4,41.4
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,7848.97,5886.73,5886.73,412.48,85.21,1228.08,,,,,,IN-LABOR CARE 2 HOUR CHARGE,,0729,,118.1,88.575,88.575
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,554,Bone diseases & arthropathies without major complications,2172.28,1629.21,1629.21,679.97,10.47,679.97,,,,,,IN-LABOR CARE 3 HOUR CHARGE,,0729,,178.6,133.95,133.95
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,462.28,114.13,1811.75,,,,,,IN-LABOR CARE 4 HOUR CHARGE,,0729,,236,177,177
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,563,"Fractures of hip, pelvis & thigh without major complications",225,168.75,168.75,369.03,120.51,550.32,,,,,,IN-LABOR CARE 5 HOUR CHARGE,,0729,,295.5,221.625,221.625
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,601,Non-malignant breast disorders without complications,957.3,717.98,717.98,0,114.13,204.41,,,,,,IN-LABOR CARE 6 HOUR CHARGE,,0729,,356.2,267.15,267.15
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,0,106.96,3862,,,,,,IN-LABOR CARE 7 HOUR CHARGE,,0729,,410.2,307.65,307.65
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,605,"Trauma to the skin, subcut tiss & breast without major complications",244.8,183.6,183.6,223.34,127.96,1897.14,,,,,,IN-LABOR CARE 8 HOUR CHARGE,,0729,,477.5,358.125,358.125
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,607,Minor skin disorders without major complications,21812.12,16359.09,16359.09,273.84,110.11,412.48,,,,,,FETAL MONITORING - EXTERNAL CHARGE,,0729,,186.4,139.8,139.8
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,637,Diabetes with major complications,6822.3,5116.73,5116.73,1512.47,103.4,31787,,,,,,FETAL MONITORING - INTER CHARGE,,0729,,356.2,267.15,267.15
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,639,Diabetes without complications,136.9,102.68,102.68,208.38,16.31,2312.51,,,,,,"LABOR RECOVERY, EA ADDTL 15 MINS CHARGE",,0729,,49.7,37.275,37.275
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,0,16.31,81.11,,,,,,94640 SUB AEROSOL TRTMT 24 HR CHARGE,,,,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,645,Endocrine disorders without complications,286.8,215.1,215.1,118.4,43.38,118.4,,,,,,63739-0440-01 - acetaminophen 325 mg Tab [REEV],,0250,63739-0440-01,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,696,Kidney & urinary tract signs & symptoms without major complications,108.1,81.08,81.08,15.66,14.28,326.3,,,,,,95833 PT MUSC TESTING TOTAL BODY EXC HANDS CHARGE,,,,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,700,Other kidney & urinary tract diagnoses without complications,3271.46,2453.6,2453.6,42.53,42.53,8584.81,,,,,,95834 PT MUSC TEST TOT BODY INCL HANDS CHARGE,,,,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,812,Anemia or other red blood cell disorders without complications,9406.09,7054.57,7054.57,167.33,18.04,3834.62,,,,,,MRI Lower Extremity w/ + w/o Cnt Left,73720,0610,,"1,974.7",1481.025,1481.025
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,2723.29,2042.47,2042.47,291.53,126.71,291.53,,,,,,MRI Lower Extremity w/ + w/o Cnt Right,73720,0610,,"1,974.7",1481.025,1481.025
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,880,Acute adjustment reaction & psychosocial dysfunction [MSDRG 880],8110.83,6083.12,6083.12,298.59,78.48,679.76,,,,,,MRI Lower Extremity w/o Contrast Left,73718,0610,,"1,046.4",784.8,784.8
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,914,Traumatic injury without major complications,225,168.75,168.75,0,114.13,336.29,,,,,,MRI Lower Extremity w/o Contrast Right,73718,0610,,"1,046.4",784.8,784.8
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,935,Non-extensive burns,9054.97,6791.23,6791.23,141.96,121.56,141.96,,,,,,MRI Upper Extremity w/o Contrast Left,73218,0610,,"1,046.4",784.8,784.8
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",9266.42,6949.82,6949.82,0,18.69,580.69,,,,,,MRI Upper Extremity w/o Contrast Right,73218,0610,,"1,046.4",784.8,784.8
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,950,Aftercare without complications,80133.85,60100.39,60100.39,46.39,8.7,689.32,,,,,,99152 MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,0450,,27.7,20.775,20.775
BCBS OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,0,51.31,199.63,,,,,,00143-9888-80 - amoxicillin 125 mg/5 mL Oral Liq (BOTTLE) [REEV],,0250,00143-9888-80,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,00143-9886-50 - amoxicillin 200 mg/5 mL Oral Liq [REEV],,0250,00143-9886-50,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,00093-2026-31 - azithromycin 200 mg/5 mL Oral Liq (bottle) [REEV],,0250,00093-2026-31,,,
BCBS OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,62,55.34,245.75,,,,,,00781-6139-57 - amoxicillin-clavulanate 600 mg-42.9 mg/5 mL Oral Liq 75 Ml (bottle) [REEV],,0250,00781-6139-57,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,902,Anesthesia provided during anus and rectum procedure [HCPCS 00902],139,104.25,104.25,6.02,6,17.45,,,,,,00574-0121-04 - charcoal 25 g Oral Susp 120 mL [REEV],,0250,00574-0121-04,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,0,3.36,245.34,,,,,,54838-0001-80 - ferrous sulfate 220 mg/5 mL Oral Elix [REEV],,0250,54838-0001-80,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,46260,Multiple internal and external hemorrhoid groups removal [HCPCS 46260],1977.9,1483.43,1483.43,770.31,496.99,770.31,,,,,,00121-1276-00 - dextromethorphan-guaifenesin 20 mg-200 mg/10 mL UD [REEV],,0250,00121-1276-00,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,0,583.91,1462.85,,,,,,00005-4344-62 - Multiple Vitamins with Minerals Oral Liq 240 mL [REEV],,0250,00005-4344-62,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,76.8,52.38,170.1,,,,,,50383-0775-17 - lidocaine oral 2% Sol 15 mL [REEV],,0250,50383-0775-17,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,41.75,22.37,41.75,,,,,,70710-1165-06 - oseltamivir 6 mg/mL Pow (bottle) [REEV],,0250,70710-1165-06,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,76.8,59.99,274.04,,,,,,51672-4069-01 - phenytoin 125 mg/5 mL Oral Susp [REEV],,0250,51672-4069-01,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,101.03,77,101.03,,,,,,46122-0051-03 - simethicone 40 mg/0.6 mL Oral Liq [REEV],,0250,46122-0051-03,,,
BCBS OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,44.36,38.82,44.36,,,,,,65862-0496-47 - sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [REEV],,0250,65862-0496-47,,,
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,45802-0060-01 - bacitracin Top 500 units/g Oint [REEV],,0250,45802-0060-01,,,
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,8.87,8.87,355.2,,,,,,51672-2002-01 - clotrimazole Top 1% Crm [REEV],,0250,51672-2002-01,,,
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,6.53,6,88.2,,,,,,00904-7822-31 - clotrimazole Top 1% Crm [REEV],,0250,00904-7822-31,,,
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,11.87,8.17,155.5,,,,,,MRI Lower Extremity w/ Contrast Left,73719,0610,,"1,227.2",920.4,920.4
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,MRI Lower Extremity w/ Contrast Right,73719,0610,,"1,227.2",920.4,920.4
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,29.48,29.48,105,,,,,,MRI Upper Extremity w/ + w/o Cnt Left,73220,0610,,"1,974.7",1481.025,1481.025
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,433.2,28.6,1161.38,,,,,,MRI Upper Extremity w/ + w/o Cnt Right,73220,0610,,"1,974.7",1481.025,1481.025
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,76.05,4.51,1156.79,,,,,,MRI Upper Extremity w/ Contrast Left,73219,0610,,"1,974.7",1481.025,1481.025
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,193.61,29.4,2785.69,,,,,,MRI Upper Extremity w/ Contrast Right,73219,0610,,"1,974.7",1481.025,1481.025
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,237.46,39.1,434.06,,,,,,31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE TechFee,31500,0450,,567.9,425.925,425.925
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,373.35,61.48,2109.82,,,,,,BD Bone Density DEXA Axial w/Frac Assess,77085,0409,,286.1,214.575,214.575
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,10.77,3.22,2266.54,,,,,,BD Bone Density DEXA Vert Fracture Assmt,77086,0409,,212.4,159.3,159.3
BCBSTX MEDICAID STAR/CHIP/STAR KIDS - Medicaid,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,28.21,5.49,347.63,,,,,,32551 TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAIN TechFee,32551,0450,,"3,014.3",2260.725,2260.725
BENEFIT ADMINISTRATIVE SYSTEMS - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,183.92,39.1,434.06,,,,,,36556 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> TechFee,36556,0450,,"3,014.4",2260.8,2260.8
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,8.19,2.44,580.94,,,,,,36558 INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> TechFee,36558,0450,,"7,281",5460.75,5460.75
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,36600,Collection of blood specimen from arterial puncture for diagnosis [HCPCS 36600],293.6,220.2,220.2,0,39.78,171.67,,,,,,43752 NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE TechFee,43752,0450,,959.2,719.4,719.4
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,0,20.71,250.4,,,,,,46083 INCISION THROMBOSED HEMORRHOID EXTERNAL TechFee,46083,0450,,638.4,478.8,478.8
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,106.08,28.74,271.3,,,,,,51702 INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE TechFee,51702,0450,,293.3,219.975,219.975
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,552.37,272.21,1200.54,,,,,,62270 SPINAL PUNCTURE LUMBAR DIAGNOSTIC TechFee,62270,0450,,"1,650.5",1237.875,1237.875
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,0,8.49,161,,,,,,65205 REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL TechFee,65205,0450,,293.3,219.975,219.975
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,96.16,8.87,355.2,,,,,,65210 RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR TechFee,65210,0450,,959.2,719.4,719.4
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,29.75,2.66,76.2,,,,,,65222 RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP TechFee,65222,0450,,293.3,219.975,219.975
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,0,5.81,65.1,,,,,,65235 RMVL FB INTRAOCULAR ANT CHAMBER EYE/LENS TechFee,65235,0450,,"5,284.4",3963.3,3963.3
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,82803,Lab analysis to measure the amount of blood gases [HCPCS 82803],293.3,219.98,219.98,0,26.5,223.7,,,,,,67938 REMOVAL EMBEDDED FOREIGN BODY EYELID TechFee,67938,0450,,781.8,586.35,586.35
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,75.89,9.72,190.22,,,,,,69210 ED TECH/PF REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT,69210,0450,,154.4,115.8,115.8
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,0,32.98,268.8,,,,,,92950 ED TECH CARDIOPULMONARY RESUSCITATION,92950,0450,,695.8,521.85,521.85
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,0,9.87,141.2,,,,,,92960 CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL TechFee,92960,0450,,"1,450.9",1088.175,1088.175
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,34.5,6,88.2,,,,,,Stress Test,93017,0482,,469.7,352.275,352.275
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,55.19,9.2,112.32,,,,,,XR Femur 2 Views Bilat,,,,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,0,7.24,496.86,,,,,,68462-0298-17 - betamethasone-clotrimazole Top 0.05%-1% Crm [REEV],,0250,68462-0298-17,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,0,2.84,108.1,,,,,,00904-7623-31 - hydrocortisone Top 1% Crm [REEV],,0250,00904-7623-31,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,0,6.8,52.43,,,,,,16864-0680-02 - benzocaine Top 20% Spry [REEV],,0250,16864-0680-02,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,60.8,8.17,155.5,,,,,,51672-1312-00 - mupirocin Top 2% Oint [REEV],,0250,51672-1312-00,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,0,6.15,4344.87,,,,,,45802-0143-70 - bacitracin/neomycin/polymyxin B Top Oint (pkt) [REEV],,0250,45802-0143-70,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,0,16.49,98.36,,,,,,00081-0798-88 - bacitracin-polymyxin B Top Oint [REEV],,0250,00081-0798-88,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,32.77,19.15,448.97,,,,,,67877-0124-25 - silver sulfADIAZINE Top 1% Crm [REEV],,0250,67877-0124-25,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,63.55,16.26,2475.42,,,,,,54162-0000-02 - vitamin A & D Top Oint [REEV],,0250,54162-0000-02,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,293.52,68.61,524.17,,,,,,REEV PACU,,0710,,0,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,130.64,29.4,2785.69,,,,,,REEV IntraOp,,,,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,25.98,12.56,48.28,,,,,,REEV Phase II,,0710,,0,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,0,140.59,428.4,,,,,,60505-0829-01 - fluticasone Nasal 0.05 mg/inh Spry [REEV],,0250,60505-0829-01,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,252.54,61.48,2109.82,,,,,,69536-0025-15 - phenylephrine nasal 0.25% Sol 15 mL [REEV],,0250,69536-0025-15,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,224.73,50,3116.59,,,,,,24208-0295-25 - dexamethasone-tobramycin Ophth 0.1%-0.3% Susp [REEV],,0250,24208-0295-25,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,0,5.83,3301.98,,,,,,00074-7362-01 - carbamide peroxide Otic 6.5% Sol [REEV],,0250,00074-7362-01,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,0,0.68,2868.2,,,,,,61314-0645-11 - hydrocortisone/neomycin/polymyxin B Otic Susp [REEV],,0250,61314-0645-11,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,0,13.53,65.14,,,,,,ANESTHESIA FACILITY FEE (OUT OF DEPARTMENT),,0370,,27.7,20.775,20.775
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,0,2.1,2819.66,,,,,,ANES - EMERGENCY INTUBATION,,0370,,425.6,319.2,319.2
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,5.39,0.95,3583.7,,,,,,ANES - SPINAL TAP,,0370,,244.8,183.6,183.6
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J2920,Methylprednisolone injection [HCPCS J2920],25,18.75,18.75,0,5.3,21.25,,,,,,69097-0318-87 - budesonide 0.25 mg/2 mL Inh Susp [REEV],J7626,0250,69097-0318-87,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,12.54,5.49,347.63,,,,,,76204-0200-60 - albuterol 0.083% Inh Sol 3 mL [REEV],J7613,0250,76204-0200-60,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,1.76,23.48,,,,,,69097-0319-87 - budesonide 0.5 mg/2 mL Inh Susp [REEV],J7633,0250,69097-0319-87,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,0,2.4,4.25,,,,,,76204-0100-60 - ipratropium 0.02% Inh Sol 2 mL [REEV],J7644,0250,76204-0100-60,,,
BLUE CROSS MEDICARE ADVANTAGE C/O PROVIDER SVCS - Medicare Part A,Hospital,Institutional,Outpatient,J7620,Albuterol ipratrop non-comp [HCPCS J7620],5.47,4.1,4.1,0,2.41,4.65,,,,,,66993-0023-27 - levalbuterol 1.25 mg/3 mL Inh Sol [REEV],J7614,0250,66993-0023-27,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Inpatient,684,Renal failure without complications,7068.59,5301.44,5301.44,23.34,23.34,17582.82,,,,,,76204-0900-25 - levalbuterol 1.25 mg/3 mL Inh Sol [REEV],J7614,0250,76204-0900-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,6.2,6.2,81.6,,,,,,76204-0800-24 - levalbuterol 0.63 mg/3 mL Inh Sol [REEV],J7614,0250,76204-0800-24,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,5.3,4.51,1156.79,,,,,,59310-0579-22 - albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [REEV],,0250,59310-0579-22,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],380.5,285.38,285.38,0,131.45,310.8,,,,,,00591-3508-04 - cloNIDine 0.1 mg/24 hr Transderm ER Film [REEV],,0250,00591-3508-04,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,47.14,35.11,337.46,,,,,,31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE ProFee,31500,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,77.58,70.45,319.43,,,,,,36410 VNPNXR 3 YEARS/> PHYS/QHP SKILL ProFee,36410,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,113.59,107.28,315.01,,,,,,36430 TRANSFUSION BLOOD/BLOOD COMPONENTS TechFee,36430,0391,,"1,179.7",884.775,884.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,152.19,113,283.23,,,,,,43598-0447-70 - nicotine 14 mg/24 hr Transderm ER Film [REEV],,0250,43598-0447-70,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,0,0.11,332.88,,,,,,47781-0298-03 - nitroglycerin 0.4 mg/hr Transderm ER Film [REEV],,0250,47781-0298-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,10080,Tailbone cyst incision and drainage (simple procedure) [HCPCS 10080],1554.93,1166.2,1166.2,188.49,124.85,188.49,,,,,,66758-0208-54 - scopolamine 1.5 mg Transderm ER Film [REEV],,0250,66758-0208-54,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,11104,Skin lesion biopsy with punch tool to remove sample including all layers of skin (single lesion) [HCPCS 11104],136.9,102.68,102.68,126.86,126.86,126.86,,,,,,45802-0732-30 - acetaminophen 120 mg Supp [REEV],,0250,45802-0732-30,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,11402,"Removal of non-cancerous skin lesion of trunk, arms, or legs (1.1 to 2.0 cm) [HCPCS 11402]",739.9,554.93,554.93,251.52,69.3,251.52,,,,,,00574-7090-12 - hydrocortisone 25 mg Supp [REEV],,0250,00574-7090-12,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,11441,"Removal of non-cancerous skin lesion of face, ears, eyelids, nose, lips, or mouth (0.6 to 1.0 cm) [HCPCS 11441]",516,387,387,516,516,516,,,,,,00574-7226-12 - prochlorperazine 25 mg Supp [REEV],,0250,00574-7226-12,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,11981,Drug delivery implant insertion [HCPCS 11981],442.2,331.65,331.65,145.96,141.6,226.23,,,,,,00409-2344-01 - DOBUTamine 12.5 mg/mL IV Sol [REEV],J1250,0250,00409-2344-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,11982,Drug delivery implant removal [HCPCS 11982],189.5,142.13,142.13,161.82,161.82,250.81,,,,,,00143-9924-90 - ceFAZolin 1 g Inj (PHS) [REEV],J0690,0250,00143-9924-90,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,17340,Acne treatment by freezing [HCPCS 17340],339.7,254.78,254.78,53.7,53.7,53.7,,,,,,00143-9857-25 - cefTRIAXone 1 g Inj (PHS) [REEV],J0696,0250,00143-9857-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],339.4,254.55,254.55,72.62,72.62,77.09,,,,,,59762-4537-01 - medroxyPROGESTERone 150 mg/mL IM Susp PHS [REEV],,0250,59762-4537-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,20605,Medium joint or joint capsule fluid removal and/or injection with needle [HCPCS 20605],314.4,235.8,235.8,51.9,51.9,80.44,,,,,,63323-0664-01 - diphenhydrAMINE 50 mg/mL Inj Sol (PHS) [REEV],J1200,0250,63323-0664-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,61.63,61.63,100.1,,,,,,00024-2792-10 - sodium ferric gluconate complex 12.5 mg/mL IV Sol (PHS) [REEV],J2916,0250,00024-2792-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,51701,Temporary bladder catheter insertion [HCPCS 51701],372.7,279.53,279.53,66.83,43.71,98.46,,,,,,00641-6043-25 - ketorolac 60 mg/2 mL (PHS) [REEV],J1885,0250,00641-6043-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,56605,External female genitals biopsy (1 lesion) [HCPCS 56605],486.3,364.73,364.73,87.58,87.58,135.74,,,,,,25021-0701-02 - ketorolac 60 mg/2 mL (PHS) [REEV],J1885,0250,25021-0701-02,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,57454,Cervix biopsy and scraping with endoscope [HCPCS 57454],807.1,605.33,605.33,234.16,196.34,248.58,,,,,,00143-9622-01 - labetalol 5 mg/mL IV Sol (PHS) [REEV],,0250,00143-9622-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,58100,Uterine lining biopsy [HCPCS 58100],552.5,414.38,414.38,138.92,121.93,147.47,,,,,,47781-0586-29 - labetalol 5 mg/mL IV Sol (PHS) [REEV],,0250,47781-0586-29,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,58300,Intra-uterine device (IUD) placement for pregnancy prevention [HCPCS 58300],345.2,258.9,258.9,119.97,119.97,127.36,,,,,,66993-0022-27 - levalbuterol 0.63 mg/3 mL Inh Sol PHS [REEV],,0250,66993-0022-27,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,58301,Intra-uterine device (IUD) removal for pregnancy prevention [HCPCS 58301],169.9,127.43,127.43,142.07,114.89,150.82,,,,,,PEAK FLOW CHARGE,94799,0410,,75,56.25,56.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.51,2.07,19.9,,,,,,SPUTUM INDUCTION TREATMENT CHARGE,94799,0410,,83.8,62.85,62.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.77,5.3,61.31,,,,,,BREATHING EXERCISE CHARGE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,NEGATIVE INSPIRARTORY CHARGE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,11.08,1.28,46.3,,,,,,PD/PERC-INITIAL CHARGE,94667,0410,,83.8,62.85,62.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,5.3,5.3,5.3,,,,,,99465 NEWBORN RESUSCITATION CHARGE ProFee,99465,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",5.3,3.98,3.98,5.3,5.3,5.3,,,,,,NT-proBNP FSI,83880,0300,,282.3,211.725,211.725
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,238.21,156.33,346.97,,,,,,Hemoglobin FSI,85018,0300,,10,7.5,7.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90662,Influenza vaccine for injection into muscle (preservation free) [HCPCS 90662],50,37.5,37.5,50,46.94,50,,,,,,12870-0001-02 - silver nitrate Top Stick [REEV],,0250,12870-0001-02,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,15.77,15.77,25,,,,,,68084-0813-09 - pantoprazole 40 mg Oral EC Tab [REEV],,0250,68084-0813-09,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90707,"Measles, mumps, and rubella (German measles) vaccine for injection beneath skin [HCPCS 90707]",122.9,92.18,92.18,61.45,61.45,104.33,,,,,,64380-0799-01 - oseltamivir 75 mg Cap [REEV],,0250,64380-0799-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,39.7,36.98,63.97,,,,,,00245-0212-11 - midodrine 5 mg Tab (PHS) [REEV],,0250,00245-0212-11,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,85.05,85.05,170.1,,,,,,45802-0201-26 - acetaminophen 160 mg/5 mL Oral Susp [REEV],,0250,45802-0201-26,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90732,Pneumococcal polysaccharide vaccine for injection beneath the skin or into muscle (2 years of age or older) [HCPCS 90732],315.6,236.7,236.7,129.23,129.23,140.17,,,,,,00409-4277-02 - lidocaine 2% Sol,J2001,0250,00409-4277-02,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,165.79,134.02,193.88,,,,,,00409-4277-01 - lidocaine 2% 20 mL MDV Sol [REEV],J2001,0250,00409-4277-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90746,"Hepatitis B vaccine injection into muscle (adult dosage, 3 dose schedule) [HCPCS 90746]",155.4,116.55,116.55,75.24,75.24,76.08,,,,,,00006-5423-12 - sugammadex 100 mg/mL Sol [REEV],,0250,00006-5423-12,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,90750,Shingles vaccine for injection into muscle [HCPCS 90750],446.6,334.95,334.95,161.36,161.36,446.6,,,,,,00409-1754-10 - magnesium sulfate 50% Sol [REEV],J3475,0250,00409-1754-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,ABO-UBS,86900,0300,,79.4,59.55,59.55
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,79.81,45.56,141.93,,,,,,RH GROUP-UBS,86901,0300,,79.4,59.55,59.55
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,113.22,91.42,145.6,,,,,,ABO GROUP,86900,0300,,58.5,43.875,43.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,168.53,140.39,202.54,,,,,,RH TYPE,86901,0300,,58.5,43.875,43.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,23.3,8.98,23.86,,,,,,ADRENAL AB,86255,0300,,115.9,86.925,86.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,46.23,13.55,72.8,,,,,,ADRENAL TITER,86256,0300,,115.9,86.925,86.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,76.08,62.38,245.75,,,,,,TUGLOBULIN CLOT LYSIS TIME,85360,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,111.38,70,166.6,,,,,,FIBRINOGEN DEGRADATION PROD,85362,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,149.24,147.2,226.48,,,,,,FIBRIN MONOMER,85362,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],68.4,51.3,51.3,68.4,68.4,240.69,,,,,,D DIMER QUANTATIVE,85379,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99382,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99382],68.4,51.3,51.3,68.4,68.4,245.75,,,,,,ALPHA 2 ANTIPLASIM,85410,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,PLASMINOGEN ACTIVATOR INHIB,85415,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,TISSUE PLASMINOGEN ACTIVATOR,85415,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,68.4,55.34,245.75,,,,,,PLASMINOGEN ACTIVITY,85420,0300,,202.9,152.175,152.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,ATTEROARIA ALTERNOTA IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,68.4,68.4,245.75,,,,,,"ASPERGILLUS FUMIGATUS,",86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],68.4,51.3,51.3,68.4,68.4,245.75,,,,,,"BERMUDA GRASS, IGE",86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,BIRCH T3 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,99397,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (65 years of age and older) [HCPCS 99397],68.4,51.3,51.3,68.4,68.4,68.4,,,,,,CAT DANDER EL IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.35,14.35,372.57,,,,,,RAST-CLADOSPORIUM HERB,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,COCKROACHILE I6 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J1030,Methylprednisolone 40 mg inj [HCPCS J1030],26.3,19.73,19.73,4.94,4.94,5.92,,,,,,COMMON RAGWEED SHORT WL IGE,86003,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,COTTONWOOD +14 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0.08,0.08,6.58,,,,,,DERMATAPHAGOIDES PTERONY,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,26.3,5.44,26.3,,,,,,DERMATOPHAGOIDES PTERONYSSINUSAD,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],26.3,19.73,19.73,2.35,1.11,2.45,,,,,,DOG DANDER E2 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],26.3,19.73,19.73,5.39,5.39,19.43,,,,,,RAST-ELM,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,MAPLE BOX ELDER,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],31.5,23.63,23.63,4.88,1.8,4.88,,,,,,"MOUNTAIN CEDAR, IGE",86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Clinic,Professional,Outpatient,J7307,Etonogestrel implant system [HCPCS J7307],628.5,471.38,471.38,628.5,628.5,628.5,,,,,,NETTLE W2 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Dialysis Clinic,Institutional,Outpatient,90962,Dialysis services by physician with 1 visit per month (20 years of age and older) [HCPCS 90962],1386,1039.5,1039.5,187.77,187.77,187.77,,,,,,"OAK, IGE",86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,289.04,214.38,2255.8,,,,,,"HICKORY/PECAN TREE, IG",86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Dialysis Clinic,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,242.91,242.91,1540,,,,,,PENICILLIUM NOTATUM ML IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,57,Degenerative nervous system disorders without complications,794.52,595.89,595.89,1007.81,47.44,1007.81,,,,,,ROUGH MARSH ELDER W6 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,66,Intracranial hemorrhage or cerebral infarction without complications,8926.99,6695.24,6695.24,1852.28,1852.28,3555.53,,,,,,ROUGH PIGWEED W14 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,72,Nonspecific cerebrovascular disorders without complications,1349,1011.75,1011.75,208.56,208.56,208.56,,,,,,SHEEP SORREL W18 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,74,Cranial & peripheral nerve disorders without major complications,21172.68,15879.51,15879.51,3586.14,69.6,3586.14,,,,,,WHITE MULBERRY T70 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,81,Nontraumatic stupor & coma without major complications,661.9,496.43,496.43,138.54,138.54,138.54,,,,,,TIMOTHY GRASS G6 IGE,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,90,Concussion without complications,233.1,174.83,174.83,1016.85,106.96,1016.85,,,,,,RAST-WHITE ASH,86003,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,93,Other disorders of nervous system without complications,365,273.75,273.75,1424.82,97.24,1487.7,,,,,,BILIRUBIN UNCONJUGATED,82247,0300,,118.1,88.575,88.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,101,Seizures without major complications,215.2,161.4,161.4,81.83,63.26,2316.2,,,,,,BILIRUBIN CONJUGATED,82248,0300,,118.1,88.575,88.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,103,Headaches without major complications,1572.2,1179.15,1179.15,787.11,44.95,787.11,,,,,,FHA IGA,86615,0300,,116.9,87.675,87.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,123,Neurological eye disorders,2307.1,1730.33,1730.33,542.77,542.77,542.77,,,,,,FHA IGG,86615,0300,,116.9,87.675,87.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,125,Other disorders of the eye without major complications,244.8,183.6,183.6,121.56,78.84,127.96,,,,,,PT IGA,86615,0300,,116.9,87.675,87.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,149,Dysequilibrium,6776.96,5082.72,5082.72,801.47,646.37,2020.84,,,,,,PT IGG,86615,0300,,116.9,87.675,87.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,151,Epistaxis without major complications,1399.95,1049.96,1049.96,83.07,83.07,393.15,,,,,,C PNEUMONIAE IGA,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,152,Otitis media & URI with major complications,810.8,608.1,608.1,1119,87.23,1119,,,,,,C PNEUMONIAE IGG,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,19.04,15.26,797.02,,,,,,C PNEUMONIAE IGM,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,156,"Other ear, nose, mouth & throat diagnoses without complications",233.1,174.83,174.83,101.92,101.92,2111.4,,,,,,C PSITTACI IGA,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,159,Dental & oral diseases without complications,6084.99,4563.74,4563.74,283.54,115.65,283.54,,,,,,C PSITTACI IGG,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,178,Respiratory infections & inflammations with complications,23123.75,17342.81,17342.81,1906.72,1906.72,3760.39,,,,,,C PSITTACI IGM,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,14091.06,10568.3,10568.3,251.24,251.24,692.2,,,,,,C TRACHOMATIS DK IGA,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,185,Major chest trauma without complications,10222.93,7667.2,7667.2,2398.95,2065.77,2398.95,,,,,,C TRACHOMATIS DK IGG,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,11673.09,8754.82,8754.82,4612.24,128.55,4612.24,,,,,,C TRACHOMATIS DK IGM,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,203,Bronchitis or asthma without complications,5469.95,4102.46,4102.46,83.12,79.7,1453.4,,,,,,C TRACHOMATIS L2 IGA,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,62.11,62.11,380.62,,,,,,C TRACHOMATIS L2 IGG,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,206,Other respiratory system diagnoses without major complications,32539.25,24404.44,24404.44,789.32,65.22,789.32,,,,,,C TRACHOMATIS L2 IGM,86631,0300,,38.7,29.025,29.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,293,Heart failure & shock without complications,11691.95,8768.96,8768.96,272.06,272.06,7724,,,,,,CANDIDA ALBICANS IGG,86628,0300,,71.8,53.85,53.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,301,Peripheral vascular disorders without complications,679.4,509.55,509.55,1104.35,92.2,1519.88,,,,,,CANDIDA ALBICANS IGA,86628,0300,,71.8,53.85,53.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,303,Atherosclerosis without major complications,453.4,340.05,340.05,295.92,55.56,295.92,,,,,,CANDIDA ALBICANS IGM,86628,0300,,71.8,53.85,53.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,304,Hypertension with major complications,3243.75,2432.81,2432.81,1090.08,1090.08,1090.08,,,,,,CPK,82550,0300,,65.1,48.825,48.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,305,Hypertension without major complications,504.1,378.08,378.08,70.13,56.14,1006,,,,,,TROPONIN I,84484,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,307,Cardiac congenital & valvular disorders without major complications,483.1,362.33,362.33,125,125,184.72,,,,,,"CULTURE, ID FA, ANY SO",87140,0300,,39.7,29.775,29.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,308,Cardiac arrhythmia & conduction disorders with major complications,3482.9,2612.18,2612.18,7.89,7.89,1143.5,,,,,,DNA ANALYSIS,88233,0300,,681.4,511.05,511.05
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,310,Abnormal or Irregular Heartbeat without complications,9139.9,6854.93,6854.93,774.79,8.28,4356,,,,,,CHROMOSAL ANALYSIS,88262,0300,,681.4,511.05,511.05
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,312,Syncope & collapse,366.5,274.88,274.88,1002.31,118.11,1683.78,,,,,,TRANSLOCATION,88291,0300,,681.4,511.05,511.05
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,313,Chest pain,1698.38,1273.79,1273.79,1426.72,120.51,1434.85,,,,,,C-4 COMPLEMENT,86160,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,314,Other circulatory system diagnoses with major complications,1549.76,1162.32,1162.32,540.93,540.93,540.93,,,,,,CH-50 COMPLEMENT,86162,0300,,131.3,98.475,98.475
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,316,Other circulatory system diagnoses without complications,692.6,519.45,519.45,448.33,120.51,448.33,,,,,,CORTISOL URINE,82530,0300,,164.4,123.3,123.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,373,Major gastrointestinal disorders & peritoneal infections without complications,309.9,232.43,232.43,1796.68,56.14,1796.68,,,,,,DFA FOR CRYTOSORIDIUM,87272,0300,,68.4,51.3,51.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,378,Digestive System Bleeding with complications,2462.2,1846.65,1846.65,148.98,148.98,148.98,,,,,,CYCLOSPORA,87015,0300,,96,72,72
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,379,G.I. hemorrhage without complications,4664.75,3498.56,3498.56,357.69,272.1,3830.58,,,,,,ISOSPORA,87207,0300,,96,72,72
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,387,Inflammatory bowel disease without complications,579,434.25,434.25,146,146,180.64,,,,,,CYP2C9,81227,0301,,510.6,382.95,382.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,390,G.I. obstruction without complications,9334.12,7000.59,7000.59,1576.1,923.86,4390.02,,,,,,VKORC1,81355,0301,,510.6,382.95,382.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,391,"Esophagitis, gastroent & misc digest disorders with major complications",19666.17,14749.63,14749.63,115.21,87.23,10409.97,,,,,,FSH,83001,0300,,220.5,165.375,165.375
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,160.27,119.23,9860.3,,,,,,LEUTENIZING HORMONE (L,83002,0300,,178.6,133.95,133.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,395,Other digestive system diagnoses without complications,14799.06,11099.3,11099.3,572.41,127.96,1406.51,,,,,,HCT,85014,0300,,10,7.5,7.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,433,Cirrhosis & alcoholic hepatitis with complications,769.9,577.43,577.43,156.75,156.75,156.75,,,,,,HEMOGLOBIN A2,83021,0300,,248.2,186.15,186.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,434,Cirrhosis & alcoholic hepatitis without complications,7993.78,5995.34,5995.34,3325.69,1372.79,3325.69,,,,,,HEMATOCRIT,85014,0300,,10,7.5,7.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,443,"Disorders of liver except malig,cirr,alc hepa without complications",744.5,558.38,558.38,67.99,67.99,394.4,,,,,,HEMOGLOBIN,85018,0300,,10,7.5,7.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,444,Disorders of the biliary tract with major complications,9507.89,7130.92,7130.92,641.28,641.28,641.28,,,,,,RBC,85041,0300,,325.3,243.975,243.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,445,Disorders of the biliary tract with complications,2148.82,1611.62,1611.62,763.74,763.74,763.74,,,,,,"IRON, QUEST",83540,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,446,Disorders of the biliary tract without complications,9747.85,7310.89,7310.89,0,2900.23,2900.23,,,,,,"IRON, SERUM",83540,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,547,Connective tissue disorders without complications,499.7,374.78,374.78,582.26,46.39,582.26,,,,,,"IRON BINDING CAPACITY,",83550,0300,,58.5,43.875,43.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,7848.97,5886.73,5886.73,114.13,85.21,1228.08,,,,,,ISLET CELL AUTO AB SCREEN,86341,0300,,88.2,66.15,66.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,554,Bone diseases & arthropathies without major complications,2172.28,1629.21,1629.21,335.82,10.47,679.97,,,,,,ISLET CELL AUTO AB TITER,86341,0300,,88.2,66.15,66.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,114.13,114.13,1811.75,,,,,,IMAGING PAP,88175,0310,,17.7,13.275,13.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,558,"Tendonitis, myositis & bursitis without major complications",4597.81,3448.36,3448.36,114.13,15.24,1106.15,,,,,,FLOW CYTOMETRY FIRST MARKER,88184,0300,,112.5,84.375,84.375
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,561,"Aftercare, musculoskeletal system & connective tissue without complications",6041.73,4531.3,4531.3,1646.82,873.07,1646.82,,,,,,FLOW CYTOMETRY EA ADDTNL,88185,0300,,900.8,675.6,675.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,563,"Fractures of hip, pelvis & thigh without major complications",225,168.75,168.75,326.3,120.51,550.32,,,,,,FLOW INTERPRETATION 9-16,88188,0300,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,566,Other musculoskeletal system & connective tissue diagnoses without complications,225,168.75,168.75,819.69,60.22,819.69,,,,,,PROTEINASE-3 ANTIBODY,86021,0300,,263.6,197.7,197.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,594,Skin ulcers without complications,4451.2,3338.4,3338.4,916.87,916.87,928.92,,,,,,ANTI NUCLEAR ABS,86038,0300,,263.6,197.7,197.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,596,Major skin disorders without major complications,776.4,582.3,582.3,101.92,101.92,226.45,,,,,,BPI igg AUTO ANTIBODIES,83520,0300,,263.6,197.7,197.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,601,Non-malignant breast disorders without complications,957.3,717.98,717.98,114.13,114.13,204.41,,,,,,PROTEIN C ACTIVITY,85303,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,121.56,106.96,3862,,,,,,PROTEIN C ANTIGEN,85302,0300,,328.6,246.45,246.45
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,605,"Trauma to the skin, subcut tiss & breast without major complications",244.8,183.6,183.6,330.98,127.96,1897.14,,,,,,PROTEIN S ANTIGEN,85305,0300,,35.3,26.475,26.475
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,607,Minor skin disorders without major complications,21812.12,16359.09,16359.09,121.56,110.11,412.48,,,,,,CREATININE(QUEST),82570,0300,,61.8,46.35,46.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,637,Diabetes with major complications,6822.3,5116.73,5116.73,323.14,103.4,31787,,,,,,"URINE, PROTEIN 24HR",84156,0300,,58.5,43.875,43.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,638,Diabetes with complications,9974.78,7481.09,7481.09,0,121.02,4314.45,,,,,,"RUBELLA ANTIBODY, IGM",86762,0300,,144.5,108.375,108.375
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,639,Diabetes without complications,136.9,102.68,102.68,16.31,16.31,2312.51,,,,,,SPERM IgA,89325,0300,,134.5,100.875,100.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,16.31,16.31,81.11,,,,,,SPERM IgG,89325,0300,,134.5,100.875,100.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,642,Inborn errors of metabolism,169.9,127.43,127.43,1824.52,31.06,1824.52,,,,,,LACTOBACILLUS SPP,87512,0300,,104.8,78.6,78.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,645,Endocrine disorders without complications,286.8,215.1,215.1,43.38,43.38,118.4,,,,,,ATOROBIUM VAGINAE,87799,0300,,104.8,78.6,78.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,682,Kidney failure with major complications,8943.93,6707.95,6707.95,1902.98,143.29,1902.98,,,,,,MEGASPHAERA SPP,87799,0300,,104.8,78.6,78.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,683,Kidney failure with complications,12430.68,9323.01,9323.01,33.75,33.75,33.75,,,,,,GARDNERELLA VAGINALIS,87799,0300,,104.8,78.6,78.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,684,Renal failure without complications,7068.59,5301.44,5301.44,23.34,23.34,17582.82,,,,,,C CBICANS DNA,87481,0300,,113.7,85.275,85.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,5253.83,3940.37,3940.37,1256.28,13.56,1256.28,,,,,,C GLABRATER DNA,87481,0300,,113.7,85.275,85.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,694,Urinary stones without lithotripsy and without major complications,2489.5,1867.13,1867.13,966.91,412.48,966.91,,,,,,C TROPICALIS DNA,87481,0300,,113.7,85.275,85.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,696,Kidney & urinary tract signs & symptoms without major complications,108.1,81.08,81.08,35.74,14.28,326.3,,,,,,C PARAPSILOSIS DNA,87481,0300,,113.7,85.275,85.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,698,Other kidney & urinary tract diagnoses with major complications,13753.84,10315.38,10315.38,185.76,185.76,185.76,,,,,,"T4, TOTAL (THRYROXIN)",84436,0300,,61.8,46.35,46.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,699,Other kidney & urinary tract diagnoses with complications,3652.38,2739.29,2739.29,254.17,254.17,792.76,,,,,,THYROID T3 UPTAKE,84479,0300,,61.8,46.35,46.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,700,Other kidney & urinary tract diagnoses without complications,3271.46,2453.6,2453.6,713.47,42.53,8584.81,,,,,,TSH,84443,0300,,135.7,101.775,101.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,726,Benign prostatic hypertrophy without major complications,2501.62,1876.22,1876.22,214.3,214.3,412.48,,,,,,"T4, FREE (THYROXINE)",84439,0300,,130.1,97.575,97.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,728,Inflammation of the male reproductive system withou major complications,1702.07,1276.55,1276.55,513.57,85.21,669.67,,,,,,ZIKA URINE,87798,0300,,637.3,477.975,477.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,730,Other male reproductive system diagnoses without complications,468.7,351.53,351.53,160.27,141.3,428.73,,,,,,ZIKA SERUM,87798,0300,,637.3,477.975,477.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,759,"Infections, female reproductive system without complications",311,233.25,233.25,231.98,162.76,231.98,,,,,,PHOSPHATIDYLSERINE IGA,86148,0300,,166.6,124.95,124.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,761,Menstrual & other female reproductive system disorders without complications,311,233.25,233.25,117.9,117.9,661.98,,,,,,PHOSPHATIDYLSERINE IGM,86148,0300,,166.6,124.95,124.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,776,Postpartum & post abortion diagnoses without operating room procedure,12218.97,9164.23,9164.23,837.7,228.95,837.7,,,,,,"HOMOCYSTEINE, CARDIOVA",83090,0300,,322,241.5,241.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,778,Threatened abortion,653.9,490.43,490.43,46.11,20.26,46.11,,,,,,ANTITHROMBIN III ACTIVITY,85300,0300,,366.1,274.575,274.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,779,Abortion without D&C,162.2,121.65,121.65,225.23,26.64,225.23,,,,,,PROTEIN C FUNCTION,85303,0300,,277.9,208.425,208.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,781,Other antepartum diagnoses w medical complications,430.5,322.88,322.88,375.96,58.92,375.96,,,,,,"PROTEIN S, FUNCTION",85305,0300,,311,233.25,233.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,782,Other antepartum diagnoses without medical complications,622.7,467.03,467.03,92.76,92.76,97.4,,,,,,LUPUS ANTICOAGULANT SC,85613,0300,,161,120.75,120.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,812,Anemia or other red blood cell disorders without complications,9406.09,7054.57,7054.57,3834.62,18.04,3834.62,,,,,,HOMOCYSTEINE & MMA,82131,0300,,545.8,409.35,409.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,816,Reticuloendothelial & immunity disorders without complications,58.5,43.88,43.88,17.19,13.75,17.19,,,,,,PROTHROMBIN FACTOR II 20210G MUT ANALYSI,81240,0310,,282.3,211.725,211.725
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,2921.19,2190.89,2190.89,285.42,285.42,711.2,,,,,,FACTOR V (LEIDEN) MUTUTATION ANALYSIS,81241,0310,,615.2,461.4,461.4
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,2723.29,2042.47,2042.47,130.9,126.71,291.53,,,,,,AGE BASED PAP,87624,0310,,17.7,13.275,13.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,842,Lymphoma & non-acute leukemia without complications,109.2,81.9,81.9,124.29,13.75,130.84,,,,,,HPV,87625,0310,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,845,Other myeloprolif dis or poorly diff neopl diag without complications,1917.05,1437.79,1437.79,348.55,101.43,348.55,,,,,,PROTEIN S. ANTIGENIC,85305,0300,,281.2,210.9,210.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,863,Postoperative & post-traumatic infections without major complications,3464.85,2598.64,2598.64,1430.11,1430.11,1430.11,,,,,,PROTEIN S ACTIVITY,85306,0300,,281.2,210.9,210.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,866,Viral illness without major complications,2386.03,1789.52,1789.52,415.75,415.75,829.47,,,,,,PROT S ANTIGEN FREE,85306,0300,,281.2,210.9,210.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,869,Other infectious & parasitic diseases diagnoses without complications,1066.4,799.8,799.8,172.81,15.01,172.81,,,,,,C4b BINDING PROTEIN,86329,0300,,281.2,210.9,210.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,880,Acute adjustment reaction & psychosocial dysfunction [MSDRG 880],8110.83,6083.12,6083.12,679.76,78.48,679.76,,,,,,VITAMIN B-12,82607,0300,,124.7,93.525,93.525
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,887,Other mental disorder diagnoses,956.2,717.15,717.15,147.98,127.96,147.98,,,,,,"FOLATE, SERUM",82746,0300,,113.7,85.275,85.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,897,Alcohol or Drug Abuse without rehab or major complications [MSDRG 897],4590.55,3442.91,3442.91,814.67,814.67,2177.16,,,,,,TISSUE TRANSGLUTAMINASE IGA W REFLEXES,83516,0300,,102.6,76.95,76.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,914,Traumatic injury without major complications,225,168.75,168.75,114.13,114.13,336.29,,,,,,GLIADIN ANTIBODY IGA,83516,0300,,102.6,76.95,76.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,916,Allergic reactions without major complications,5755.84,4316.88,4316.88,430.54,127.96,430.54,,,,,,TOTAL IGA WITH REFLEX,83516,0300,,102.6,76.95,76.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,918,Drug poisoning without complications,6285.29,4713.97,4713.97,815.06,815.06,815.06,,,,,,GAMMAGLOBULIN,83516,0300,,102.6,76.95,76.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,921,Complications of treatment without complications,124.7,93.53,93.53,1356.33,1356.33,1356.33,,,,,,CLAM F207 IgE,86003,0300,,44.1,33.075,33.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,923,"Other injury, poisoning & toxic effect diag without major complications",366.5,274.88,274.88,487.62,236.65,1149.69,,,,,,CODFISH F3 IgE,86003,0300,,44.1,33.075,33.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,935,Non-extensive burns,9054.97,6791.23,6791.23,121.56,121.56,141.96,,,,,,EGG WHITE IGE,86003,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",9266.42,6949.82,6949.82,40.65,18.69,580.69,,,,,,CORN IGE,86003,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,950,Aftercare without complications,80133.85,60100.39,60100.39,8.7,8.7,689.32,,,,,,COWS MILK IGE,86003,0300,,44.1,33.075,33.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,83.12,51.31,199.63,,,,,,PEANUT IGE,86003,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Institutional,Inpatient,998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,452.1,339.08,339.08,294.9,76.18,294.9,,,,,,SCALLOP F338 IgE,86003,0300,,44.1,33.075,33.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,11104,Skin lesion biopsy with punch tool to remove sample including all layers of skin (single lesion) [HCPCS 11104],136.9,102.68,102.68,126.86,126.86,126.86,,,,,,SESAME SEED F10 IgE,86003,0300,,44.1,33.075,33.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,11982,Drug delivery implant removal [HCPCS 11982],189.5,142.13,142.13,161.82,161.82,250.81,,,,,,SHRIMP IGE,86003,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],339.4,254.55,254.55,72.62,72.62,77.09,,,,,,SOYBEAN IGE,86003,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,61.63,61.63,100.1,,,,,,WALNUT IGE,86003,0300,,44.1,33.075,33.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.51,2.07,19.9,,,,,,WHEAT IGE,86003,0300,,50.8,38.1,38.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,5.77,5.3,61.31,,,,,,STRIATED MUSCLE WITH RELFEX,86255,0300,,187.5,140.625,140.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,STRIATED AB TITIER,84999,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,11.08,1.28,46.3,,,,,,ACHR BINDING AB,83519,0300,,302.1,226.575,226.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,39.7,36.98,63.97,,,,,,"CARDIOLIPIN IGG,IGM,IG",86147,0302,,116.9,87.675,87.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,"ANTIBODY, RBC PANEL)",86870,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,79.81,45.56,141.93,,,,,,TITER/TITER,86886,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,113.22,91.42,145.6,,,,,,"AB, TYPING RBC",86905,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,168.53,140.39,202.54,,,,,,PHOSPHATIDYLSERINE IGG,86148,0302,,166.6,124.95,124.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,23.3,8.98,23.86,,,,,,BFTA 2 GLYCOPROTEIN IG,86146,0305,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,46.23,13.55,72.8,,,,,,CANDIDA SPECIES,87480,0300,,135.7,101.775,101.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,76.08,62.38,245.75,,,,,,TRICHOMONAS VAGINATIS,87660,0300,,135.7,101.775,101.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,111.38,70,166.6,,,,,,GARDNERELLA VAGINATIS,87510,0300,,135.7,101.775,101.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,"ARSENIC, BLOOD",82175,0300,,226.1,169.575,169.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.35,14.35,372.57,,,,,,CADMIUM (FOR PANEL),82300,0300,,56.3,42.225,42.225
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,"LEAD, BLOOD",83655,0300,,123.5,92.625,92.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,"MERCURY, BLOOD",83825,0300,,233.8,175.35,175.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0.08,0.08,6.58,,,,,,SJOGREN'S AB,86235,0300,,220.5,165.375,165.375
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,26.3,5.44,26.3,,,,,,SM (SMITH) ANTIBODY,86235,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],26.3,19.73,19.73,2.35,1.11,2.45,,,,,,"C-3, COMPLEMENT",86160,0300,,145.6,109.2,109.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Hospital,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,"SCL-70AB, EIA",86235,0300,,205.1,153.825,153.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Institutional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",314,235.5,235.5,74.98,55.67,329.7,,,,,,STRIATED MUSCLE AB,86255,0300,,233.8,175.35,175.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Institutional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],194.3,145.73,145.73,98.64,73.93,98.64,,,,,,RHEUMATOID FACTOR (RA),86431,0300,,186.4,139.8,139.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Institutional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],83,62.25,62.25,43.32,35.71,43.32,,,,,,RIBOSOMAL P PROTEIN AB,83520,0300,,272.4,204.3,204.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,300,Anesthesia provided during esophagus and neck procedure [HCPCS 00300],139,104.25,104.25,16.99,6.45,46.89,,,,,,RETICULIN IGA W/RFLX T,86255,0302,,116.9,87.675,87.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,5.08,3.97,330,,,,,,MITOCHONDRIAL AB W/TIT,86255,0300,,116.9,87.675,87.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,635,Anesthesia provided during spinal tap [HCPCS 00635],139,104.25,104.25,59.63,59.63,59.63,,,,,,ACTH,82024,0300,,362.8,272.1,272.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,790,Anesthesia provided during procedure in upper abdomen with use of an endoscope [HCPCS 00790],139,104.25,104.25,1.97,1.97,425.11,,,,,,DNA AB (DS) CRITH,86255,0300,,94.9,71.175,71.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,4.88,1.64,80.91,,,,,,GASTRIC PARIETAL CELL,83516,0300,,78.4,58.8,58.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,5.6,1.93,464.4,,,,,,THYROID PEROXIDASE AB/ANTI-MICROSOMAL AB,86376,0300,,121.3,90.975,90.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,830,Anesthesia provided during lower abdominal hernia repair [HCPCS 00830],139,104.25,104.25,3.91,1.95,28.42,,,,,,TOTAL B CELL COUNT,86355,0300,,147.8,110.85,110.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,832,Anesthesia provided during middle or incisional abdominal hernia repair [HCPCS 00832],139,104.25,104.25,4.64,4.64,85.14,,,,,,NATURAL KILLER CELL TO,86357,0300,,147.8,110.85,110.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,4.8,4.8,352,,,,,,TOTAL T CELL,86359,0300,,147.8,110.85,110.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,851,Anesthesia provided during tying or incision of fallopian tubes using an endoscope [HCPCS 00851],139,104.25,104.25,5.72,5.72,268.49,,,,,,ABSOLUTE LYMPHOCYTE CD,86360,0300,,147.8,110.85,110.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,902,Anesthesia provided during anus and rectum procedure [HCPCS 00902],139,104.25,104.25,6,6,17.45,,,,,,"ALPHA FETO PROTEIN, TU",82105,0300,,139,104.25,104.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,952,Anesthesia provided during uterus examination using an endoscope [HCPCS 00952],139,104.25,104.25,6.03,5.79,184.83,,,,,,INHIBIN - A,86336,0300,,209.5,157.125,157.125
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,1960,Anesthesia provided during vaginal delivery [HCPCS 01960],139,104.25,104.25,1.24,1.24,296.76,,,,,,ESTRIOL,82677,0300,,167.6,125.7,125.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,1961,Anesthesia provided during cesarean delivery [HCPCS 01961],139,104.25,104.25,5.8,5.74,329.73,,,,,,"BHCG, TOTAL QUANTITATI",84702,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,5.27,3.36,245.34,,,,,,"ALPHA FETO PROTIEN, SER",82105,0300,,167.6,125.7,125.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,1968,Anesthesia provided during cesarean delivery following labor [HCPCS 01968],139,104.25,104.25,2.99,2.99,188.42,,,,,,CHEMILUMINESCENT ASSAY,82397,0300,,167.6,125.7,125.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,11400,"Removal of non-cancerous skin lesion of trunk, arms, or legs (0.5 cm or less) [HCPCS 11400]",664.9,498.68,498.68,664.9,130.15,664.9,,,,,,CMV TEST SCREENING,86645,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,11403,"Removal of non-cancerous skin lesion of trunk, arms, or legs (2.1 to 3.0 cm) [HCPCS 11403]",932.8,699.6,699.6,932.8,237.41,932.8,,,,,,"HSV 1&2 IGM,IGG AB",86694,0300,,311,233.25,233.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,11406,"Removal of non-cancerous skin lesion of trunk, arms, or legs (over 4.0 cm) [HCPCS 11406]",1250.3,937.73,937.73,256.24,238.72,397.16,,,,,,"RUBELLA ANTIBODY, IGG",86762,0300,,237.1,177.825,177.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,11420,"Removal of non-cancerous skin lesion of scalp, neck, hands, feet, or genitalia (0.5 cm or less) [HCPCS 11420]",2978.6,2233.95,2233.95,200,200,200,,,,,,TOXOPLASMA IGG ANTIBOD,86777,0300,,134.5,100.875,100.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,11441,"Removal of non-cancerous skin lesion of face, ears, eyelids, nose, lips, or mouth (0.6 to 1.0 cm) [HCPCS 11441]",516,387,387,516,516,516,,,,,,"TOXO ANTIBODY, IGM",86778,0300,,97.1,72.825,72.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,12032,"Intermediate repair of wound of scalp, underarms, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12032]",1113.6,835.2,835.2,100.55,100.55,100.55,,,,,,HSV 1 IgG ANTIBODY,86695,0300,,96,72,72
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,19120,"Breast cyst removal, male or female (1 or more cysts) [HCPCS 19120]",1884.3,1413.23,1413.23,429.6,429.6,429.6,,,,,,HSV 2 IGM ANTIBODY,86696,0300,,96,72,72
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,21556,Muscle tumor removal from neck or front of chest (less than 5 cm) [HCPCS 21556],1970.3,1477.73,1477.73,547.45,547.45,547.45,,,,,,ABO(IN-HOUSE)BLOOD TYPE,86900,0300,,61.8,46.35,46.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],2617.4,1963.05,1963.05,627.82,627.82,973.08,,,,,,RH (BLOOD TYPE),86901,0300,,48.6,36.45,36.45
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,194.98,51.74,302.2,,,,,,ANTIBODY SCREEN,86850,0300,,78.4,58.8,58.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,308.88,192.01,343.2,,,,,,"COOMBS TEST, DIRECT",86880,0300,,75,56.25,56.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,392.02,168.37,416.16,,,,,,CROSSMATCH (BLOOD) 1,86920,0300,,123.5,92.625,92.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,46260,Multiple internal and external hemorrhoid groups removal [HCPCS 46260],1977.9,1483.43,1483.43,496.99,496.99,770.31,,,,,,BRUCELLA ANTIBODIES IGG,86622,0300,,118.1,88.575,88.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,49505,Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505],1904.1,1428.08,1428.08,0,503.48,841.81,,,,,,BRUCELLA ANTIBODIES IGM,86622,0300,,118.1,88.575,88.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,49655,Initial abdominal hernia repair with endoscope (herniated tissue that is trapped) [HCPCS 49655],3718.8,2789.1,2789.1,1077.96,1077.96,1077.96,,,,,,HERPES SIMPLEX VIRUS,87254,0300,,167.6,125.7,125.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,58301,Intra-uterine device (IUD) removal for pregnancy prevention [HCPCS 58301],169.9,127.43,127.43,142.07,114.89,150.82,,,,,,VARICELLA-ZOSTER VIRUS CULTURE,87254,0300,,167.6,125.7,125.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],7445.3,5583.98,5583.98,370.97,127.52,393.81,,,,,,DESMOGLEIN 1 ANTIBODY,83520,0300,,76.2,57.15,57.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,58605,Fallopian tubes tying or incision during same hospitalization [HCPCS 58605],1347.3,1010.48,1010.48,336.97,336.97,336.97,,,,,,DESMOGLEIN 3 ANTIBODY,83520,0300,,76.2,57.15,57.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,58611,Fallopian tubes tying or incision at time of cesarean delivery or other abdominal surgery [HCPCS 58611],423.4,317.55,317.55,0,9.22,121.22,,,,,,BLASTOMYCES ABIgG,86612,0300,,164.4,123.3,123.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,58662,Ovary or pelvic tumot destruction or removal with endoscope [HCPCS 58662],3077.2,2307.9,2307.9,1063.98,564.75,1063.98,,,,,,BLASTOMYCES ABIgM,86612,0300,,164.4,123.3,123.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,58670,Ovaries destrustion with endoscope [HCPCS 58670],2552.4,1914.3,1914.3,186.15,186.15,276.66,,,,,,Q-FEVER I AB IgG,86638,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,58671,Blocking of uterine tubes by device with endoscope [HCPCS 58671],1591,1193.25,1193.25,544.09,275.86,577.59,,,,,,Q-FEVER II AB IgG,86638,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,44.73,22.99,68.3,,,,,,Q-FEVER I AB IgM,86638,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,59400,Delivery of infant through uterus and vagina with obstetric care before and after delivery [HCPCS 59400],3596.4,2697.3,2697.3,3179.83,3179.83,3245.09,,,,,,Q-FEVER II AB IgM,86638,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,842.25,583.91,1462.85,,,,,,GLIADIN AB IGG,83516,0300,,162.2,121.65,121.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,59410,Delivery of infant through uterus and vagina with obstetric care after delivery [HCPCS 59410],2050.7,1538.03,1538.03,1079.04,1079.04,1672.45,,,,,,GLIADIN AB IGA,83516,0300,,162.2,121.65,121.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,948.93,138.2,1470.79,,,,,,BETA 2 GLYCOPROTEIN IgG,86146,0300,,176.4,132.3,132.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,59622,Delivery of infant through incision in abdomen and uterus (cesarean delivery) following vaginal delivery attempt with obstetric care after delivery (patient had previos cesarean delivery) [HCPCS 59622],5136.6,3852.45,3852.45,1972.72,1972.72,2094.19,,,,,,BETA 2 GLYCOPROTEIN IgA,86146,0300,,176.4,132.3,132.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,23.3,8.98,23.86,,,,,,BETA 2 GLYCOPROTEIN IgM,86146,0300,,176.4,132.3,132.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,46.23,13.55,72.8,,,,,,PROTHROMBIN TIME PT,85610,0300,,127.9,95.925,95.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,74.98,52.38,170.1,,,,,,ACTIVATED PARTIAL THROBOPLASTIN TIME PTT,85730,0300,,127.9,95.925,95.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,102.28,52.53,206.9,,,,,,TOTAL PROTEIN,84155,0300,,53,39.75,39.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,142.17,81.71,178.67,,,,,,PROTEIN ELECTROPHORESIS,84165,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,104.1,59.92,194.57,,,,,,PROTEIN IMMUNOFIXATION,86334,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,143.28,95.05,222.03,,,,,,CHLAMYDIA,87110,0300,,204.1,153.075,153.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,207.48,120.14,248.05,,,,,,GONORRHOEAE,87591,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,41.57,22.37,41.75,,,,,,TRANSGLUTAMINASE AB IGG,83516,0300,,176.4,132.3,132.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,74.98,39.55,134.08,,,,,,TRANSGLUTAMINASE AB IGA,83516,0300,,176.4,132.3,132.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,40.4,31.68,51.15,,,,,,"CREATININE, URINE",82570,0300,,97.1,72.825,72.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,76.1,45.48,91.29,,,,,,ORGANIC ACIDS 63,83919,0301,,495.1,371.325,371.325
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],257,192.75,192.75,108.76,99.96,130.9,,,,,,GDH ANTIGEN,87449,0301,,213.9,160.425,160.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,136.5,114.76,176.55,,,,,,TOXIN A & B,87324,0301,,213.9,160.425,160.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99235,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235],458.7,344.03,344.03,173.63,142.98,177.83,,,,,,HIV 1 GENOTYPE,87901,0300,,"1,153.3",864.975,864.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,74.98,59.99,274.04,,,,,,HIV PHENOTYPE,87903,0301,,"1,206.2",904.65,904.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,112.1,33.41,326.4,,,,,,HIV ADDNL DRUGS TESTED,87904,0301,,53,39.75,39.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],415.7,311.78,311.78,92.46,86.79,92.46,,,,,,FISH,88271,0300,,161,120.75,120.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,45.14,41.76,46.23,,,,,,AML M3,88271,0300,,161,120.75,120.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,98.64,77,101.03,,,,,,PML/RARA,88275,0300,,161,120.75,120.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,43.32,38.82,44.36,,,,,,"TRANSLOCATION 15,17",88291,0300,,161,120.75,120.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,LEUKEMIA EVALUATION,88189,0300,,107,80.25,80.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,VIALBILITY,88184,0300,,26.5,19.875,19.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,CD MARKERS,88185,0300,,2.2,1.65,1.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,"CMV,CONVENTIONAL",87252,0306,,201.9,151.425,151.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,76.08,62.38,245.75,,,,,,RAPID CULTURE,87254,0306,,201.9,151.425,151.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,"MYCROBACTERIA PCR, MIS",87556,0300,,389.3,291.975,291.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,103,Headaches without major complications,1572.2,1179.15,1179.15,729.85,44.95,787.11,,,,,,"CULTURE, MYCOBACTERIUM",87116,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,125,Other disorders of the eye without major complications,244.8,183.6,183.6,78.84,78.84,127.96,,,,,,CONCENTRATION TECHNIQUE,87015,0300,,68.4,51.3,51.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,14091.06,10568.3,10568.3,383.05,251.24,692.2,,,,,,ACID FAST STAIN (ABF),87206,0300,,55.2,41.4,41.4
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,195,Pneumonia without complications,11673.09,8754.82,8754.82,128.55,128.55,4612.24,,,,,,CD18 EXPRESSION LAD-1,88184,0300,,246,184.5,184.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,313,Chest pain,1698.38,1273.79,1273.79,573.35,120.51,1434.85,,,,,,CD15S EXPRESSION LAD-2,88185,0300,,246,184.5,184.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,893.42,119.23,9860.3,,,,,,ACETYCHOLINE RECEPTOR BINDING AB,83519,0300,,317.6,238.2,238.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,7848.97,5886.73,5886.73,244.8,85.21,1228.08,,,,,,ACETYCHOLINE RECEPTOR BLOCKING,83519,0300,,317.6,238.2,238.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,563,"Fractures of hip, pelvis & thigh without major complications",225,168.75,168.75,407.35,120.51,550.32,,,,,,ACETYCHOLINE RECEPTOR MODULATING,83519,0300,,317.6,238.2,238.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,106.96,106.96,3862,,,,,,ANTIBODY TO TP ANTIGEN(IGM),86635,0300,,69.6,52.2,52.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,696,Kidney & urinary tract signs & symptoms without major complications,108.1,81.08,81.08,326.3,14.28,326.3,,,,,,ANTIBODY TO F ANTIGEN (IGG),86635,0300,,69.6,52.2,52.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,199.63,51.31,199.63,,,,,,49884-0465-65 - cholestyramine 4 g Pow UD [REEV],,0250,49884-0465-65,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,0,95.05,222.03,,,,,,Streptococcus pneumoniae Ab IgG (23 Serotypes),86317,0300,,51,38.25,38.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Indemnity,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,0,45.48,91.29,,,,,,GI Biopsy #2 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,86580 TB Skin Test,86580,0521,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.89,5.3,61.31,,,,,,GI Biopsy #3 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,GI Biopsy #4 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,GI Biopsy #5 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,90662,Influenza vaccine for injection into muscle (preservation free) [HCPCS 90662],50,37.5,37.5,50,46.94,50,,,,,,GI Biopsy #6 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,21.33,15.77,25,,,,,,GI Biopsy #7 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,39.7,36.98,63.97,,,,,,GI Biopsy #8 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,134.1,134.02,193.88,,,,,,Gynecologic Biopsy #2 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,90750,Shingles vaccine for injection into muscle [HCPCS 90750],446.6,334.95,334.95,161.36,161.36,446.6,,,,,,Gynecologic Biopsy #3 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,Gynecologic Biopsy #4 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,113.7,91.42,145.6,,,,,,Gynecologic Biopsy #5 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,168.53,140.39,202.54,,,,,,Gynecologic Biopsy #6 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,Skin Biopsy #2 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,Skin Biopsy #3 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,114.08,70,166.6,,,,,,Skin Biopsy #4 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,Skin Biopsy #5 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.35,14.35,372.57,,,,,,Skin Biopsy #6 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,Skin Biopsy #7 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,Skin Biopsy #8 REF,88305,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0,0.08,6.58,,,,,,Surgical Procedure #2 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,Surgical Procedure #3 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,Surgical Procedure #4 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,60,Multiple sclerosis & cerebellar ataxia without complications,824.2,618.15,618.15,217.85,175,217.85,,,,,,Surgical Procedure #5 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,74,Cranial & peripheral nerve disorders without major complications,21172.68,15879.51,15879.51,176.44,69.6,3586.14,,,,,,Surgical Procedure #6 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,93,Other disorders of nervous system without complications,365,273.75,273.75,1487.7,97.24,1487.7,,,,,,Surgical Procedure #7 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,101,Seizures without major complications,215.2,161.4,161.4,935.56,63.26,2316.2,,,,,,Surgical Procedure #8 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,103,Headaches without major complications,1572.2,1179.15,1179.15,44.95,44.95,787.11,,,,,,Surgical Procedure #9 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,125,Other disorders of the eye without major complications,244.8,183.6,183.6,127.96,78.84,127.96,,,,,,Surgical Procedure #10 REF,88302,0310,,33.1,24.825,24.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,149,Dysequilibrium,6776.96,5082.72,5082.72,646.37,646.37,2020.84,,,,,,Urinalysis Dipstick Only FSI,81003,0300,,53,39.75,39.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,152,Otitis media & URI with major complications,810.8,608.1,608.1,87.23,87.23,1119,,,,,,INHIBIN 'A' / PANEL,86336,0300,,167.6,125.7,125.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,107.2,15.26,797.02,,,,,,"J2675 Injection, progesterone, per 50 mg, 100mg vial",J2675,0521,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,156,"Other ear, nose, mouth & throat diagnoses without complications",233.1,174.83,174.83,2111.4,101.92,2111.4,,,,,,"J2675 Injection, progesterone, per 50 mg, 200mg vial",J2675,0521,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,14091.06,10568.3,10568.3,576.55,251.24,692.2,,,,,,"J1080 Injection, testosterone cypionate, 1 cc, 200 mg",J1080,0521,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,195,Pneumonia without complications,11673.09,8754.82,8754.82,291.48,128.55,4612.24,,,,,,"90648 Hib PRP-T Conjugate 4 dose schedule IM, Hiberix",90648,0521,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,203,Bronchitis or asthma without complications,5469.95,4102.46,4102.46,1453.4,79.7,1453.4,,,,,,"90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use 10mc",90744,0521,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,65.22,62.11,380.62,,,,,,"90727 Plague vaccine, for intramuscular use",,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,305,Hypertension without major complications,504.1,378.08,378.08,1006,56.14,1006,,,,,,00100 ANES SALIVARY GLAND ProFee,00100,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,310,Abnormal or Irregular Heartbeat without complications,9139.9,6854.93,6854.93,8.28,8.28,4356,,,,,,00120 ANES EXTERNAL AND INNER EAR ProFee,00120,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,312,Syncope & collapse,366.5,274.88,274.88,1683.78,118.11,1683.78,,,,,,00124 ANES EXTERNAL MIDDLE & INNER EAR W/BX OTOSCOPY ProFee,00124,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,313,Chest pain,1698.38,1273.79,1273.79,624.81,120.51,1434.85,,,,,,00126 ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY ProFee,00126,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,373,Major gastrointestinal disorders & peritoneal infections without complications,309.9,232.43,232.43,56.14,56.14,1796.68,,,,,,00140 ANESTHESIA EYE NOT OTHERWISE SPECIFIED ProFee,00140,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,379,G.I. hemorrhage without complications,4664.75,3498.56,3498.56,272.1,272.1,3830.58,,,,,,00322 ANES ESOPH THYRD LARX TRACH & LYMPH NCK BX THYRD ProFee,00322,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,390,G.I. obstruction without complications,9334.12,7000.59,7000.59,4390.02,923.86,4390.02,,,,,,00350 ANESTHESIA MAJOR VESSELS NECK NOS ProFee,00350,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,1187.37,119.23,9860.3,,,,,,00400 ANES INTEG EXTREMITIES ANT TRUNK & PERINEUM NOS ProFee,00400,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,395,Other digestive system diagnoses without complications,14799.06,11099.3,11099.3,169.24,127.96,1406.51,,,,,,00404 ANESTHESIA RADICAL/MODIFIED RADICAL BREAST ProFee,00404,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,7848.97,5886.73,5886.73,686.88,85.21,1228.08,,,,,,00406 ANES RADICAL/MODIFIED RADICAL BREAST W/NODES ProFee,00406,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,0,114.13,1811.75,,,,,,00520 ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY NOS ProFee,00520,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,558,"Tendonitis, myositis & bursitis without major complications",4597.81,3448.36,3448.36,1106.15,15.24,1106.15,,,,,,00522 ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA ProFee,00522,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,563,"Fractures of hip, pelvis & thigh without major complications",225,168.75,168.75,550.32,120.51,550.32,,,,,,00524 ANESTHESIA CLOSED CHEST PNEUMOCENTESIS ProFee,00524,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,593,Skin ulcers with complications,2710.2,2032.65,2032.65,1897.14,1897.14,1897.14,,,,,,00530 ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION ProFee,00530,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,596,Major skin disorders without major complications,776.4,582.3,582.3,176.44,101.92,226.45,,,,,,00700 ANESTHESIA UPPER ANTERIOR ABDOMINAL WALL NOS ProFee,00700,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,544,106.96,3862,,,,,,00731 ANESTHESIA UPPER GI ENDOSCOPIC PX NOS ProFee,00731,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,605,"Trauma to the skin, subcut tiss & breast without major complications",244.8,183.6,183.6,1897.14,127.96,1897.14,,,,,,00732 ANESTHESIA UPPER GI ENDOSCOPIC PX ERCP ProFee,00732,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,607,Minor skin disorders without major complications,21812.12,16359.09,16359.09,412.48,110.11,412.48,,,,,,00750 ANESTHESIA HERNIA REPAIR UPPER ABDOMEN NOS ProFee,00750,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,639,Diabetes without complications,136.9,102.68,102.68,2312.51,16.31,2312.51,,,,,,00752 ANES HRNA RPR UPR ABD LMBR&VENTRAL HERNIA&DEHISC ProFee,00752,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,0,16.31,81.11,,,,,,00756 ANES HRNA REPAIR UPR ABD TABDL RPR DIPHRG HRNA ProFee,00756,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,644,Endocrine disorders with complications,4348.5,3261.38,3261.38,887.74,323.87,887.74,,,,,,00790 ANES INTRAPERITONEAL UPPER ABDOMEN W/LAPS NOS ProFee,00790,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,645,Endocrine disorders without complications,286.8,215.1,215.1,75.69,43.38,118.4,,,,,,00792 ANES LAPS PARTIAL HEPATECTOMY W/MGMT LIVER HEMOR ProFee,00792,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,696,Kidney & urinary tract signs & symptoms without major complications,108.1,81.08,81.08,14.28,14.28,326.3,,,,,,00800 ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL NOS ProFee,00800,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,724,"Malignancy, male reproductive system without complications",320.3,240.23,240.23,42.65,42.65,42.65,,,,,,00802 ANES LOWER ANT ABDOMINAL WALL PANNICULECTOMY ProFee,00802,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,728,Inflammation of the male reproductive system withou major complications,1702.07,1276.55,1276.55,343.75,85.21,669.67,,,,,,00811 ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS ProFee,00811,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,761,Menstrual & other female reproductive system disorders without complications,311,233.25,233.25,661.98,117.9,661.98,,,,,,00812 ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC ProFee,00812,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,781,Other antepartum diagnoses w medical complications,430.5,322.88,322.88,62.42,58.92,375.96,,,,,,00813 ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX ProFee,00813,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,811,Red blood cell disorders with major complications,10642.45,7981.84,7981.84,683.23,42.53,683.23,,,,,,00820 ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL ProFee,00820,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,2723.29,2042.47,2042.47,126.71,126.71,291.53,,,,,,00830 ANESTHESIA HERNIA REPAIR LOWER ABDOMEN NOS ProFee,00830,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,842,Lymphoma & non-acute leukemia without complications,109.2,81.9,81.9,130.84,13.75,130.84,,,,,,00840 ANESTHESIA INTRAPERITONEAL LOWER ABD W/LAPS NOS ProFee,00840,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,880,Acute adjustment reaction & psychosocial dysfunction [MSDRG 880],8110.83,6083.12,6083.12,493.48,78.48,679.76,,,,,,00848 ANES IPER LOWER ABD W/LAPS PELVIC EXENTERATION ProFee,00848,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,885,Mental Illness [MSDRG 885],947.4,710.55,710.55,705.12,126.93,705.12,,,,,,00851 ANES IPER LWR ABD W/LAPS TUBAL LIGATION/TRANSECT ProFee,00851,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,914,Traumatic injury without major complications,225,168.75,168.75,336.29,114.13,336.29,,,,,,00864 ANES XTRPRTL LWER ABD W/URINARY TRACT TOT CYSTEC ProFee,00864,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,916,Allergic reactions without major complications,5755.84,4316.88,4316.88,223.34,127.96,430.54,,,,,,00902 ANESTHESIA ANORECTAL PROCEDURE ProFee,00902,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,921,Complications of treatment without complications,124.7,93.53,93.53,0,1356.33,1356.33,,,,,,00920 ANESTHESIA MALE GENITALIA INCL OPEN URETHRAL PX ProFee,00920,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,923,"Other injury, poisoning & toxic effect diag without major complications",366.5,274.88,274.88,236.65,236.65,1149.69,,,,,,00921 ANES VASECTOMY UNI/BI INCL OPEN URETHRAL PX ProFee,00921,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,947,Signs & symptoms with major complications,13422.45,10066.84,10066.84,462.88,65.22,462.88,,,,,,00924 ANES UNDSCND TESTIS UNI/BI INCL OPEN URTL PX ProFee,00924,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",9266.42,6949.82,6949.82,580.69,18.69,580.69,,,,,,00928 ANES RAD ORCHIECTOMY ABDOMINAL INCL OPN URTL ProFee,00928,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,00948 ANESTHESIA CERVICAL CERCLAGE INCLUDING BIOPSY ProFee,00948,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,0,2.07,19.9,,,,,,00950 ANESTHESIA CULDOSCOPY INCLUDING BIOPSY ProFee,00950,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.89,5.3,61.31,,,,,,00952 ANES HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX ProFee,00952,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,01490 ANES LOWER LEG CAST APPLICATION REMOVAL/REPAIR ProFee,01490,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,01710 ANES NRV MUSC TDN FSCA&BRS UPR ARM/ELBOW NOS ProFee,01710,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,01810 ANES NERVE MUSCLE TDN FASCIA&BURSA FOREARM WRIST ProFee,01810,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,01850 ANESTHESIA VEINS FOREARM WRIST & HAND NOS ProFee,01850,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,114.08,70,166.6,,,,,,01860 ANES FOREARM WRIST/HAND CAST APPL RMVL/REPAIR ProFee,01860,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Hospital,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,01966 ANESTHESIA INDUCED ABORTION ProFee,01966,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,6.51,3.97,330,,,,,,01999 UNLISTED ANESTHESIA PROCEDURE ProFee,01999,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,14.18,3.36,245.34,,,,,,36556 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> ProFee,36556,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,11403,"Removal of non-cancerous skin lesion of trunk, arms, or legs (2.1 to 3.0 cm) [HCPCS 11403]",932.8,699.6,699.6,237.41,237.41,932.8,,,,,,99116 ANES COMPLICJ UTILIZATION TOTAL BODY HYPOTHERMIA ProFee,99116,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,47.48,22.99,68.3,,,,,,00500 ANESTHESIA ESOPHAGUS ProFee,00500,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,1305.45,583.91,1462.85,,,,,,00770 ANESTHESIA MAJOR ABDOMINAL BLOOD VESSELS ProFee,00770,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,76.8,52.38,170.1,,,,,,00870 ANES XTRPRTL LWR ABD W/URIN TRACT CSTOLITHOTOMY ProFee,00870,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,0,52.53,206.9,,,,,,00630 ANESTHESIA LUMBAR REGION NOS ProFee,00630,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,106.62,59.92,194.57,,,,,,00635 ANES DIAGNOSTIC/THERAPEUTIC LUMBAR PUNCTURE ProFee,00635,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,41.75,22.37,41.75,,,,,,00170 ANESTHESIA INTRAORAL WITH BIOPSY NOS ProFee,00170,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,76.42,45.48,91.29,,,,,,00300 ANES INTEG MUSC & NRV HEAD NECK&POSTERIOR TRUNK ProFee,00300,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,139.8,114.76,176.55,,,,,,00320 ANES ESOPH THYRD LARYNX TRACH & LYMPH NECK 1YR ProFee,00320,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,76.8,59.99,274.04,,,,,,87804 IAADIADOO INFLUENZA TechFee,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,2255.8,214.38,2255.8,,,,,,SURFACTANT ADMIN THRU TUBE CHARGE,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,2255.8,214.38,2255.8,,,,,,FLUTTER VALVE CHARGE,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,21,2.44,580.94,,,,,,CBC w/o Diff FSI,85027,0300,,37.5,28.125,28.125
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,271.3,28.74,271.3,,,,,,CATHETER TROCAR 24 FR.,,0272,,37.22,27.915,27.915
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,161,8.49,161,,,,,,10060 INCISION & DRAINAGE ABSCESS,10060,0761,,709,531.75,531.75
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,37.5,5.43,37.5,,,,,,10140 I&D OF HEMATOMA SEROMA OR FLUID COLLECT,10140,0761,,"5,725.4",4294.05,4294.05
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,69.6,3.6,69.6,,,,,,10140 DEBRIDE/REM OF ECZ TISSUE OR INFECTED,11001,0761,,0,,
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,69.6,6.03,69.6,,,,,,11042 DEBRIDE SUBQ TISS 1ST 20CM,11042,0761,,"1,355.1",1016.325,1016.325
"ADMINISTRATIVE CONCEPTS, INC. - Medicare Part B",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,122.5,6.15,4344.87,,,,,,11043 DEBRIDE MUCS/FASCIA 1ST 20CM,11043,0761,,"2,098.2",1573.65,1573.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Inpatient,683,Kidney failure with complications,12430.68,9323.01,9323.01,0,33.75,33.75,,,,,,11044 DEBRIDE BONE 1ST 20CM,11044,0761,,"5,725.4",4294.05,4294.05
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Inpatient,684,Renal failure without complications,7068.59,5301.44,5301.44,17582.82,23.34,17582.82,,,,,,11045 DEBRIDE SUBQ TISS EA ADDNL,11045,0761,,132.3,99.225,99.225
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,0,2.09,3.53,,,,,,11046 DEBRIDE MUCS/FASCIA EA ADDTNL,11046,0761,,282.3,211.725,211.725
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,6.89,6.2,81.6,,,,,,11047 DEBRIDE BONE EA ADDTNL 20CM,11047,0761,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,279.97,279.97,287,,,,,,11100 BIOPSY(SKIN SUBC),,0761,,"1,355.1",1016.325,1016.325
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,163.81,163.81,163.81,,,,,,16000 INITIAL TREATMENT 1ST DEGREE BURN,16000,0761,,709,531.75,531.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,5.3,4.51,1156.79,,,,,,16020 DSG AND/OR DEBR PRTL THICK SM,16020,0761,,709,531.75,531.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,47.35,35.11,337.46,,,,,,16025 DSG AND/OR DEBR PRTL THICK MED,16025,0761,,709,531.75,531.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,77.92,70.45,319.43,,,,,,16030 DSG AND/OR DEBR PRTL THICK LG,16030,0761,,"1,355.1",1016.325,1016.325
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,238.4,113,283.23,,,,,,17250 CHEM CAUTERIZATION GRAN TISSUE,17250,0761,,709,531.75,531.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99384,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99384],65.1,48.83,48.83,65.1,65.1,240.69,,,,,,29580 APPL OF UNNA BOOT,29580,0761,,580,435,435
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,65.1,65.1,240.69,,,,,,29581 APPL OF MULTILAYER VENOUS WND COMP,29581,0761,,580,435,435
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,26.3,0.68,2868.2,,,,,,97597 DEBRIDE DEVIT TISS 1ST 20CM,97597,0761,,709,531.75,531.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Institutional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],1.25,0.94,0.94,2.15,1.41,29.34,,,,,,97598 DEBRIDE DEVIT TISS EA ADDTNL,97598,0761,,54.1,40.575,40.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,10061,Abscess incision and drainage (complicated procedure or multiple abscesses) [HCPCS 10061],638.4,478.8,478.8,327.9,176.75,327.9,,,,,,97602 ACTIVE WND MNGNT NON SEL DEBRID,97602,0761,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,10120,Incision into deepest layer of skin for foreign body removal (simple procedure) [HCPCS 10120],1325.2,993.9,993.9,208.5,208.5,208.5,,,,,,97605 NPWT <-50SQ CM WOUND VAC DME,97605,0761,,709,531.75,531.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,11200,Skin tag removal (up to and including 15 tags) [HCPCS 11200],255.8,191.85,191.85,243.6,243.6,243.6,,,,,,97606 NPWT >-50SQ CM WOUND VAC DME,97606,0761,,"1,355.1",1016.325,1016.325
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,11201,Skin tag removal (each additional 10 tags) [HCPCS 11201],46,34.5,34.5,90.3,24.2,90.3,,,,,,99201 NP VISIT LEVEL 1,99201,0761,,116.3,87.225,87.225
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,11981,Drug delivery implant insertion [HCPCS 11981],442.2,331.65,331.65,226.23,141.6,226.23,,,,,,99202 NP VISIT LEVEL 2,99202,0761,,230.5,172.875,172.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,11982,Drug delivery implant removal [HCPCS 11982],189.5,142.13,142.13,250.81,161.82,250.81,,,,,,99203 NP VISIT LEVEL 3,99203,0761,,380.5,285.375,285.375
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,11983,Drug delivery implant removal with reinsertion [HCPCS 11983],1604.3,1203.23,1203.23,366.44,366.44,366.44,,,,,,99204 NP VISIT LEVEL 4,99204,0761,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",491.8,368.85,368.85,141.33,141.33,141.33,,,,,,99205 NP VISIT LEVEL 5,99205,0761,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,17340,Acne treatment by freezing [HCPCS 17340],339.7,254.78,254.78,0,53.7,53.7,,,,,,99211 EST PT VISIT LEV 1,99211,0761,,46.3,34.725,34.725
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],339.4,254.55,254.55,77.09,72.62,77.09,,,,,,99212 EST PT VISIT LEV 2,99212,0761,,124.7,93.525,93.525
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,20605,Medium joint or joint capsule fluid removal and/or injection with needle [HCPCS 20605],314.4,235.8,235.8,80.44,51.9,80.44,,,,,,99213 EST PT VISIT LEV 3,99213,0761,,254.8,191.1,191.1
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,95.52,61.63,100.1,,,,,,99214 EST PT VISIT LEV 4,99214,0761,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,51701,Temporary bladder catheter insertion [HCPCS 51701],372.7,279.53,279.53,70.94,43.71,98.46,,,,,,99215 EST PT VISIT LEV 5,99215,0761,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,56605,External female genitals biopsy (1 lesion) [HCPCS 56605],486.3,364.73,364.73,135.74,87.58,135.74,,,,,,11000 DEBRIDE/REM OF ECZEMATOUS TISSUE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,56820,External female genitals examination with endoscope [HCPCS 56820],489.6,367.2,367.2,183.22,183.22,183.22,,,,,,00904-6730-61 - acetaminophen 500 mg Tab [REEV],,0250,00904-6730-61,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,57452,Vaginal and cervix examination with endoscope [HCPCS 57452],540.3,405.23,405.23,181.55,181.55,181.55,,,,,,Microalbumin Rand Ur REF,82043,0300,,26.5,19.875,19.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,57500,Cervix biopsy or excision of lesion [HCPCS 57500],623,467.25,467.25,212.27,212.27,212.27,,,,,,Varicella Zoster Virus IgG Ab REF,86787,0300,,148.9,111.675,111.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,58100,Uterine lining biopsy [HCPCS 58100],552.5,414.38,414.38,147.47,121.93,147.47,,,,,,"Mumps Virus IgG, EIA REF",86735,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,58300,Intra-uterine device (IUD) placement for pregnancy prevention [HCPCS 58300],345.2,258.9,258.9,127.36,119.97,127.36,,,,,,.ANA Titer&Pattern REF,86039,0300,,91.6,68.7,68.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,58301,Intra-uterine device (IUD) removal for pregnancy prevention [HCPCS 58301],169.9,127.43,127.43,150.82,114.89,150.82,,,,,,.RPR Titer REF,86593,0300,,30.9,23.175,23.175
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.78,2.07,19.9,,,,,,.Anti-Mullerian REF,82397,0300,,232.7,174.525,174.525
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.89,5.3,61.31,,,,,,Homocysteine REF,83090,0300,,322,241.5,241.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,86580,Lab skin analysis for tuberculosis [HCPCS 86580],27.7,20.78,20.78,6.92,6.92,6.92,,,,,,.HSV2 Inhibition REF,86696,0300,,413.5,310.125,310.125
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,.CK Isoenzymes REF,82552,0300,,90.4,67.8,67.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,.Sodium (U) REF,,0300,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,5.3,5.3,5.3,,,,,,.HSV 1 IgM Titer REF,86695,0300,,194.1,145.575,145.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",5.3,3.98,3.98,5.3,5.3,5.3,,,,,,.HSV 2 IgM Titer REF,86696,0300,,194.1,145.575,145.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90632,Hepatitis A vaccine for injection into muscle (adult dosage) [HCPCS 90632],210.5,157.88,157.88,89.71,89.71,89.71,,,,,,.17 Hydroxyprog. 60 REF,83498,0300,,99.9,74.925,74.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,238.21,156.33,346.97,,,,,,.17 Hydroxyprog. Bl REF,83498,0300,,199.6,149.7,149.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90662,Influenza vaccine for injection into muscle (preservation free) [HCPCS 90662],50,37.5,37.5,46.94,46.94,50,,,,,,.Lupus Anticoag Hex REF,85598,0300,,132.3,99.225,99.225
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,15.77,15.77,25,,,,,,.DRVVT Confirm REF,85597,0300,,132.3,99.225,99.225
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90707,"Measles, mumps, and rubella (German measles) vaccine for injection beneath skin [HCPCS 90707]",122.9,92.18,92.18,102.15,61.45,104.33,,,,,,.Rubella IgM Ab REF,86762,0300,,144.5,108.375,108.375
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,59.06,36.98,63.97,,,,,,".Centromere Ab, EIA REF",86038,0300,,211.7,158.775,158.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,170.1,85.05,170.1,,,,,,.DRVVT 1:1 Mix REF,85613,0300,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90732,Pneumococcal polysaccharide vaccine for injection beneath the skin or into muscle (2 years of age or older) [HCPCS 90732],315.6,236.7,236.7,140.17,129.23,140.17,,,,,,.HTLV I/II REF,86790,0300,,341.8,256.35,256.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,165.79,134.02,193.88,,,,,,.Metanph Random Urine REF,83835,0300,,257,192.75,192.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,90750,Shingles vaccine for injection into muscle [HCPCS 90750],446.6,334.95,334.95,161.36,161.36,446.6,,,,,,.Q Fever IgG Phsi Scr REF,86638,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,.Q Fvr IgG Phs Ii Scr REF,86638,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,97169,Athletic training evaluation (typically 15 minutes) [HCPCS 97169],49.7,37.28,37.28,39.17,39.17,42.13,,,,,,.Q Fvr IgM Phsei Scr REF,86638,0300,,47.5,35.625,35.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,80.15,45.56,141.93,,,,,,.HSV Type 1 REF,86695,0300,,96,72,72
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,113.7,91.42,145.6,,,,,,.HSV Type 2 REF,86695,0300,,96,72,72
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,172.61,140.39,202.54,,,,,,.Anti C3 & Anti IgG REF,86880,0300,,160,120,120
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],281.2,210.9,210.9,216.97,185.38,251.35,,,,,,Bill Ab Titer X 1 REF,86886,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,23.86,8.98,23.86,,,,,,Bill Ab Titer X 2 REF,86886,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,Bill Ab Titer X 3 REF,86886,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,Bill Ag Type X 3 REF,86905,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,114.08,70,166.6,,,,,,Bill Ag Type X 1 REF,86905,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,152.85,147.2,226.48,,,,,,Bill Ab Panel X 1 REF,86870,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],68.4,51.3,51.3,68.4,68.4,240.69,,,,,,Bill Ab Panel X 2 REF,86870,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99382,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99382],68.4,51.3,51.3,68.4,68.4,245.75,,,,,,Bill Org Id 1 REF,87077,0300,,100.4,75.3,75.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99384,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99384],68.4,51.3,51.3,68.4,68.4,68.4,,,,,,Bill Org Id 2 REF,87077,0300,,100.4,75.3,75.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,Bill Org Id 3 REF,87077,0300,,100.4,75.3,75.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,Bill Org Id 4 REF,87077,0300,,100.4,75.3,75.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,68.4,55.34,245.75,,,,,,Bill Org Id 5 REF,87077,0300,,100.4,75.3,75.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,68.4,65.1,245.75,,,,,,Bill Org Id 6 REF,87077,0300,,100.4,75.3,75.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,68.4,68.4,245.75,,,,,,Bill Susc-1 REF,87186,0300,,172,129,129
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],68.4,51.3,51.3,68.4,68.4,245.75,,,,,,Bill Susc-2 REF,87186,0300,,172,129,129
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,Bill Susc-3 REF,87186,0300,,172,129,129
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,99397,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (65 years of age and older) [HCPCS 99397],68.4,51.3,51.3,68.4,68.4,68.4,,,,,,Bill Susc-4 REF,87186,0300,,172,129,129
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.35,14.35,372.57,,,,,,00955-1016-01 - enoxaparin 300 mg/3 mL [REEV],J1650,0250,00955-1016-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,VAPOTHERM CHARGE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J1030,Methylprednisolone 40 mg inj [HCPCS J1030],26.3,19.73,19.73,4.94,4.94,5.92,,,,,,CPAP/ BiPAP CHARGE,94660,0410,,548,411,411
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,HIGH FLOW OXYGEN CHARGE,,0270,,27.7,20.775,20.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0.08,0.08,6.58,,,,,,EZ PAP CHARGE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,26.3,5.44,26.3,,,,,,ACAPELLA CHARGE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],26.3,19.73,19.73,1.31,1.31,26.3,,,,,,IPPB CHARGE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],26.3,19.73,19.73,2.35,1.11,2.45,,,,,,6 MIN WALK TEST CHARGE,94618,0460,,293.3,219.975,219.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],26.3,19.73,19.73,5.39,5.39,19.43,,,,,,HIGH FLOW OXYGEN CHARGE,,0270,,27.7,20.775,20.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,00338-0049-41 - Sodium Chloride 0.9% IV Sol 50 mL [REEV],,0250,00338-0049-41,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],31.5,23.63,23.63,4.88,1.8,4.88,,,,,,00409-9094-25 - fentaNYL 50 mcg/mL Sol [REEV],J3010,0250,00409-9094-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J7298,"Mirena, 52 mg [HCPCS J7298]",1250.3,937.73,937.73,983.29,983.29,983.29,,,,,,00281-0326-08 - nitroglycerine 2% oint [REEV],,0250,00281-0326-08,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Clinic,Professional,Outpatient,J7307,Etonogestrel implant system [HCPCS J7307],628.5,471.38,471.38,628.5,628.5,628.5,,,,,,G0378 Hospital observation service per hour,99218,0762,,49.7,37.275,37.275
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Dialysis Clinic,Institutional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2148.3,1611.23,1611.23,448,351.42,448,,,,,,"ER PROCEDURE, SIMPLE",,0450,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Dialysis Clinic,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,448,214.38,2255.8,,,,,,"ER PROCEDURE, COMPLEX",,0450,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Dialysis Clinic,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,1540,242.91,1540,,,,,,TREATMENT ROOM,,0761,,112.5,84.375,84.375
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Dialysis Clinic,Professional,Outpatient,90962,Dialysis services by physician with 1 visit per month (20 years of age and older) [HCPCS 90962],1455.3,1091.48,1091.48,1320,199.16,1320,,,,,,"Hepatitis Panel, Acute w/Refl to Confirm REF",80074,0300,,462,346.5,346.5
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,53,Spinal disorders & injuries without complications,7313.78,5485.34,5485.34,1638.75,1638.75,1638.75,,,,,,"Tacrolimus, HS, LC/MS/MS REF",80197,0300,,389.3,291.975,291.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,57,Degenerative nervous system disorders without complications,794.52,595.89,595.89,47.44,47.44,1007.81,,,,,,"Bilirubin, Conjugated FSI",82248,0300,,118.1,88.575,88.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,60,Multiple sclerosis & cerebellar ataxia without complications,824.2,618.15,618.15,175,175,217.85,,,,,,CT Abd and Pel w/ + w/o Cont + Oral Cont,74178,0352,,"2,489.5",1867.125,1867.125
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,66,Intracranial hemorrhage or cerebral infarction without complications,8926.99,6695.24,6695.24,3555.53,1852.28,3555.53,,,,,,CT Abd w/ + w/o Contrast + Oral Contrast,74170,0352,,"1,572.2",1179.15,1179.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,69,Transient ischemia,5635.68,4226.76,4226.76,1371.65,1371.65,1371.65,,,,,,CT Abdomen and Pelvis w/ Oral Cont Only,74176,0320,,"2,489.5",1867.125,1867.125
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,74,Cranial & peripheral nerve disorders without major complications,21172.68,15879.51,15879.51,0,69.6,3586.14,,,,,,CT Abdomen w/ Oral Contrast Only,74150,0352,,"1,267.9",950.925,950.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,87,"Traumatic stupor & coma, coma <1 hr without complications",3623.9,2717.93,2717.93,799.86,799.86,799.86,,,,,,CT Pelvis w/ + w/o Cont + Oral Cont,72194,0352,,"1,572.2",1179.15,1179.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,90,Concussion without complications,233.1,174.83,174.83,106.96,106.96,1016.85,,,,,,CT Pelvis with Contrast + Oral Contrast,72194,0352,,"1,572.2",1179.15,1179.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,91,Other disorders of nervous system with major complications,390.6,292.95,292.95,194.19,194.19,194.19,,,,,,CT Pelvis with Oral Contrast,72192,0352,,"1,221.6",916.2,916.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,93,Other disorders of nervous system without complications,365,273.75,273.75,97.24,97.24,1487.7,,,,,,MRI Neck w/ +w/o Contrast,70543,0610,,"1,974.7",1481.025,1481.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,100,Seizures with major complications,11693.7,8770.28,8770.28,2577.56,2577.56,7179.93,,,,,,MRI Neck w/ Contrast,70542,0610,,"1,974.7",1481.025,1481.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,101,Seizures without major complications,215.2,161.4,161.4,63.26,63.26,2316.2,,,,,,MRI Neck w/o Contrast,70540,0610,,"1,046.4",784.8,784.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,102,Headaches with major complications,1789.05,1341.79,1341.79,708.23,708.23,708.23,,,,,,MRI Orbits w/ Contrast,70542,0610,,"1,974.7",1481.025,1481.025
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,103,Headaches without major complications,1572.2,1179.15,1179.15,198.38,44.95,787.11,,,,,,XR Finger(s) 2+ Views Bilat,73140,0320,,225,168.75,168.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,122,Acute major eye infections without complications,344.59,258.44,258.44,185.01,185.01,185.01,,,,,,XR Toe(s) 2+ Views Bilat,73660,0320,,225,168.75,168.75
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,125,Other disorders of the eye without major complications,244.8,183.6,183.6,127.96,78.84,127.96,,,,,,32909-0711-03 - barium sulfate 2% Susp [REEV],,0250,32909-0711-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,149,Dysequilibrium,6776.96,5082.72,5082.72,2020.84,646.37,2020.84,,,,,,REEV MG Tomo Charge,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,151,Epistaxis without major complications,1399.95,1049.96,1049.96,393.15,83.07,393.15,,,,,,CT Chest w/ + w/o Contrast,71270,0352,,"1,572.2",1179.15,1179.15
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,152,Otitis media & URI with major complications,810.8,608.1,608.1,361.77,87.23,1119,,,,,,CT Chest w/ Contrast,71260,0352,,"1,412.4",1059.3,1059.3
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,15.26,15.26,797.02,,,,,,CT Chest w/o Contrast,71250,0352,,"1,323",992.25,992.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,156,"Other ear, nose, mouth & throat diagnoses without complications",233.1,174.83,174.83,127.96,101.92,2111.4,,,,,,60505-0749-04 - ceFAZolin 1 g Inj [REEV],J0690,0250,60505-0749-04,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,159,Dental & oral diseases without complications,6084.99,4563.74,4563.74,127.96,115.65,283.54,,,,,,00143-9886-50 - amoxicillin 200 mg/5 mL Pow dose [REEV],,0250,00143-9886-50,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,176,Pulmonary embolism without major complications,11566.71,8675.03,8675.03,1879.39,1879.39,1879.39,,,,,,70710-1165-06 - oseltamivir 6 mg/mL Pow DOSE [REEV],,0250,70710-1165-06,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,178,Respiratory infections & inflammations with complications,23123.75,17342.81,17342.81,1925.25,1906.72,3760.39,,,,,,51645-0905-01 - thiamine 100 mg Tab [REEV],,0250,51645-0905-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,14091.06,10568.3,10568.3,291.48,251.24,692.2,,,,,,00008-0844-02 - pantoprazole 40 mg Gra UD [REEV],,0250,00008-0844-02,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,185,Major chest trauma without complications,10222.93,7667.2,7667.2,2065.77,2065.77,2398.95,,,,,,ER 2ND PROCEDURE TechFee,,0450,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,194,Pneumonia with complications,29394.9,22046.18,22046.18,2771.17,2771.17,5793,,,,,,65162-0835-94 - acyclovir topical 5% Oin [REEV],,0250,65162-0835-94,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,11673.09,8754.82,8754.82,361.77,128.55,4612.24,,,,,,17478-0283-10 - gentamicin ophthalmic 0.3% Sol [REEV],,0250,17478-0283-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,202,Bronchitis & asthma with major complications,15381.96,11536.47,11536.47,87.23,87.23,87.23,,,,,,61314-0647-25 - dexamethasone-tobramycin Ophth 0.1%-0.3% Susp [REEV],,0250,61314-0647-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,203,Bronchitis or asthma without complications,5469.95,4102.46,4102.46,87.23,79.7,1453.4,,,,,,61314-0646-10 - hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Sol [REEV],,0250,61314-0646-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,65.22,62.11,380.62,,,,,,00641-6013-10 - diltiazem 5 mg/mL IV Sol [REEV],J3490,0250,00641-6013-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,206,Other respiratory system diagnoses without major complications,32539.25,24404.44,24404.44,65.22,65.22,789.32,,,,,,49281-0545-03 - haemophilus b conjugate (PRP-T) vaccine IM Inj (PHSj [REEV],,0250,49281-0545-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,280,"Acute myocardial infarction, discharged alive with major complications",1566.2,1174.65,1174.65,1796.74,1796.74,1796.74,,,,,,00006-4119-03 - human papillomavirus vaccine 9-valent Sus (PHS) [REEV],,0250,00006-4119-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,281,"Acute myocardial infarction, discharged alive with complications",3406.89,2555.17,2555.17,1281.64,1281.64,1281.64,,,,,,00338-1145-03 - parenteral nutrition solution w/electrolytes Amino Acids 4.25% with 10% Dextrose and,,0250,00338-1145-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,282,"Acute myocardial infarction, discharged alive without complications",11247.01,8435.26,8435.26,1406.51,1406.51,1406.51,,,,,,00338-1139-03 - Amino Acids 5% with 25% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 5% with 25% Dextrose (Clinimix Sulfite-Free) Sol [REEV],,0250,00338-1139-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,291,Heart Failure with major complications,23327.8,17495.85,17495.85,286.98,286.98,3830.58,,,,,,00338-0289-47 - glycine irrigation 1.5% Sol [REEV],,0250,00338-0289-47,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,293,Heart failure & shock without complications,11691.95,8768.96,8768.96,1027.62,272.06,7724,,,,,,00409-7248-03 - hetastarch 60 mg/mL-NaCl 0.9% Sol [REEV],,0250,00409-7248-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,298,"Cardiac arrest, unexplained without complications",2080.61,1560.46,1560.46,885.79,885.79,885.79,,,,,,67457-0292-02 - naloxone 0.4 mg/mL Inj Sol [REEV],J2310,0250,67457-0292-02,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,300,Peripheral vascular disorders with complications,21336.11,16002.08,16002.08,174.72,174.72,174.72,,,,,,"11303 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion >2.0cm",,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,301,Peripheral vascular disorders without complications,679.4,509.55,509.55,1519.88,92.2,1519.88,,,,,,"Culture, Blood #2 REF",87040,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,303,Atherosclerosis without major complications,453.4,340.05,340.05,55.56,55.56,295.92,,,,,,"Culture, Blood #3 REF",87040,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,305,Hypertension without major complications,504.1,378.08,378.08,56.14,56.14,1006,,,,,,"Culture, Blood #4 REF",87040,0300,,141.2,105.9,105.9
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,307,Cardiac congenital & valvular disorders without major complications,483.1,362.33,362.33,184.72,125,184.72,,,,,,"11104 Punch biopsy of skin (including simple closure, when performed); single lesion",11104,0521,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,308,Cardiac arrhythmia & conduction disorders with major complications,3482.9,2612.18,2612.18,1143.5,7.89,1143.5,,,,,,"11105 Punch biopsy of skin (including simple closure, when performed); each separate/additional lesi",,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,309,Abnormal or Irregular Heartbeat with complications,2851.4,2138.55,2138.55,829.3,829.3,829.3,,,,,,Obstetric Panel REF,80055,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,310,Abnormal or Irregular Heartbeat without complications,9139.9,6854.93,6854.93,2000.3,8.28,4356,,,,,,.Propoxyphene Confirmation REF,80307,0300,,29.9,22.425,22.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,311,Angina pectoris,3546.08,2659.56,2659.56,1040.99,1040.99,1040.99,,,,,,.Barbiturates Confirmation REF,80345,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,312,Syncope & collapse,366.5,274.88,274.88,1441.45,118.11,1683.78,,,,,,.Phencyclidine Confirmation REF,83992,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,313,Chest pain,1698.38,1273.79,1273.79,120.51,120.51,1434.85,,,,,,REEV Barium Sulfate Orange Vanilla 2% 450 mL,,0255,,14.2,10.65,10.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,315,Other circulatory system diagnoses with complications,821.3,615.98,615.98,144.38,144.38,144.38,,,,,,REEV Barium Sulfate Banana 2% 450 mL,,0255,,14.2,10.65,10.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,316,Other circulatory system diagnoses without complications,692.6,519.45,519.45,120.51,120.51,448.33,,,,,,REEV Barium Sulfate Berry 2% 450 mL,,0255,,14.2,10.65,10.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,373,Major gastrointestinal disorders & peritoneal infections without complications,309.9,232.43,232.43,119.23,56.14,1796.68,,,,,,REEV US OB Greater than 14 Weeks Multiple Gest,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,379,G.I. hemorrhage without complications,4664.75,3498.56,3498.56,602.53,272.1,3830.58,,,,,,00143-9857-25 - cefTRIAXone 1 g Inj [REEV],J0696,0250,00143-9857-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,384,Uncomplicated peptic ulcer without major complications,439,329.25,329.25,60.76,60.76,60.76,,,,,,00143-9622-01 - labetalol 5 mg/mL IV Sol [REEV],J3490,0250,00143-9622-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,387,Inflammatory bowel disease without complications,579,434.25,434.25,180.64,146,180.64,,,,,,63323-0664-16 - diphenhydrAMINE 50 mg/mL Inj Sol [REEV],J1200,0250,63323-0664-16,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,388,G.I. obstruction with major complications,5636.45,4227.34,4227.34,1357.49,1357.49,1357.49,,,,,,68462-0639-45 - nitroglycerin 0.4 mg sublingual Tab [REEV],,0250,68462-0639-45,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,389,G.I. obstruction with complications,10647.71,7985.78,7985.78,2074.34,2074.34,2074.34,,,,,,00641-6127-25 - morphine 10 mg/mL preservative-free [REEV],J2274,0250,00641-6127-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,390,G.I. obstruction without complications,9334.12,7000.59,7000.59,923.86,923.86,4390.02,,,,,,Bill Only Fetomaternal Screen MCH,85460,0300,,123.5,92.625,92.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,391,"Esophagitis, gastroent & misc digest disorders with major complications",19666.17,14749.63,14749.63,571.45,87.23,10409.97,,,,,,Bill Only ABID MCH,86870,0300,,201.9,151.425,151.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,119.23,119.23,9860.3,,,,,,Bill Only Creatinine Clearance MCH,82575,0300,,131.3,98.475,98.475
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,394,Other digestive system diagnoses with complications,8882.48,6661.86,6661.86,1865.6,1865.6,1865.6,,,,,,Bill Only U24 Protein MCH,84156,0300,,58.5,43.875,43.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,395,Other digestive system diagnoses without complications,14799.06,11099.3,11099.3,127.96,127.96,1406.51,,,,,,Bill Only Ammonia MCH,82140,0300,,134.5,100.875,100.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,434,Cirrhosis & alcoholic hepatitis without complications,7993.78,5995.34,5995.34,1372.79,1372.79,3325.69,,,,,,Bill Only ABO/Rh UBS,,0300,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,439,Disorders of pancreas except malignancy with complications,8067.44,6050.58,6050.58,37.79,37.79,37.79,,,,,,Bill Only ABID UBS,86870,0300,,191.9,143.925,143.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,440,Disorders of pancreas except malignancy without complications,8042.43,6031.82,6031.82,2986.27,2986.27,13236.43,,,,,,Bill Only Antigen Confirm - Donor UBS,86902,0300,,160,120,120
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,441,Disorders of liver except malignancy with major complications,1271.6,953.7,953.7,198.19,198.19,198.19,,,,,,Bill Only Adsorption UBS,86978,0300,,243.7,182.775,182.775
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,443,"Disorders of liver except malig,cirr,alc hepa without complications",744.5,558.38,558.38,169.24,67.99,394.4,,,,,,Bill Only Ab Detection Scrn UBS,86850,0300,,191.9,143.925,143.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,446,Disorders of the biliary tract without complications,9747.85,7310.89,7310.89,2900.23,2900.23,2900.23,,,,,,Bill Only Direct Antiglobulin Test UBS,86880,0300,,160,120,120
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,534,Fractures of femur without major complications,1283.87,962.9,962.9,480.82,480.82,480.82,,,,,,Bill Only Extended Phenotype UBS,86905,0300,,446.6,334.95,334.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,538,"Sprains, strains, & dislocations of hip, pelvis & thigh without complications",1237.6,928.2,928.2,612.01,612.01,612.01,,,,,,Bill Only Rh Phenotype UBS,86906,0300,,191.9,143.925,143.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,541,Osteomyelitis without complications,423.5,317.63,317.63,37.22,37.22,37.22,,,,,,Bill Only Ab Detection Scrn Gel UBS,,0300,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,544,Pathological fractures & musculoskelet & conn tiss malig without complications,16808.09,12606.07,12606.07,6638.32,6638.32,6638.32,,,,,,Bill Only Treatment EGA/CHL/DTT UBS,86970,0300,,162.2,121.65,121.65
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,547,Connective tissue disorders without complications,499.7,374.78,374.78,46.39,46.39,582.26,,,,,,Bill Only Direct Antigen Test UBS,86880,0300,,69.6,52.2,52.2
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,551,Medical back problems with major complications,250.4,187.8,187.8,120.51,120.51,120.51,,,,,,Newborn Screen REF,84030,0300,,29.9,22.425,22.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,7848.97,5886.73,5886.73,501.13,85.21,1228.08,,,,,,Food Allergy Profile REF,86003,0300,,763,572.25,572.25
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,554,Bone diseases & arthropathies without major complications,2172.28,1629.21,1629.21,10.47,10.47,679.97,,,,,,"Respiratory Allergy Profile Rgn 10, OK,TX REF",,0300,,0,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,555,Signs & symptoms of musculoskeletal system & conn tissue with major complications,669.4,502.05,502.05,88.13,88.13,88.13,,,,,,Celiac Disease Comprehensive Panel REF,83516,0300,,352.8,264.6,264.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,120.51,114.13,1811.75,,,,,,"Kappa/Lambda Light Chains Ttl, Random Urine REF",83883,0301,,101.5,76.125,76.125
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,558,"Tendonitis, myositis & bursitis without major complications",4597.81,3448.36,3448.36,412.48,15.24,1106.15,,,,,,Anca Vasculitides REF,86021,0300,,507.2,380.4,380.4
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,561,"Aftercare, musculoskeletal system & connective tissue without complications",6041.73,4531.3,4531.3,873.07,873.07,1646.82,,,,,,Sm And Sm/RNP Abs REF,86235,0300,,226.1,169.575,169.575
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,563,"Fractures of hip, pelvis & thigh without major complications",225,168.75,168.75,120.51,120.51,550.32,,,,,,"Lyme Disease Ab w/Refl To Blot (IgG, IgM) REF",86617,0300,,147.8,110.85,110.85
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,565,Other musculoskeletal system & connective tissue diagnoses with complications,390.48,292.86,292.86,365.65,365.65,365.65,,,,,,Measles Ab (IgM) REF,86765,0300,,169.8,127.35,127.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,566,Other musculoskeletal system & connective tissue diagnoses without complications,225,168.75,168.75,120.51,60.22,819.69,,,,,,"Salmonella And Shigella, Culture REF",87427,0300,,54.4,40.8,40.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,594,Skin ulcers without complications,4451.2,3338.4,3338.4,928.92,916.87,928.92,,,,,,Bordetella Pertussis/ Parapertussis REF,87798,0306,,465.3,348.975,348.975
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,596,Major skin disorders without major complications,776.4,582.3,582.3,226.45,101.92,226.45,,,,,,87804 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,599,Malignant breast disorders without complications,711.9,533.93,533.93,94.54,94.54,94.54,,,,,,00574-7050-12 - bisacodyl 10 mg Supp [REEV],,0250,00574-7050-12,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,601,Non-malignant breast disorders without complications,957.3,717.98,717.98,204.41,114.13,204.41,,,,,,57896-0102-01 - acetaminophen 325 mg Tab [REEV],,0250,57896-0102-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,603,Infection of the skin,10024.81,7518.61,7518.61,215.2,106.96,3862,,,,,,00781-3408-95 - ampicillin 2 g Inj [REEV],J0290,0250,00781-3408-95,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,605,"Trauma to the skin, subcut tiss & breast without major complications",244.8,183.6,183.6,127.96,127.96,1897.14,,,,,,"Reducing Substances, Stool REF",81002,0300,,32.1,24.075,24.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,607,Minor skin disorders without major complications,21812.12,16359.09,16359.09,0,110.11,412.48,,,,,,"Antibody ID, Titer and Typing, RBC REF",86886,0300,,155.5,116.625,116.625
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,637,Diabetes with major complications,6822.3,5116.73,5116.73,103.4,103.4,31787,,,,,,US Duplex Penile Art/Veins Complete,93980,0921,,461.5,346.125,346.125
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,638,Diabetes with complications,9974.78,7481.09,7481.09,4314.45,121.02,4314.45,,,,,,US Duplex Penile Art/Veins Limited,93981,0921,,350.6,262.95,262.95
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,639,Diabetes without complications,136.9,102.68,102.68,22.51,16.31,2312.51,,,,,,Angiotensin-Converting Enzyme REF,82164,0300,,101.5,76.125,76.125
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,640,Nutritional & misc metabolic disorders with major complications,6598.22,4948.67,4948.67,1549.16,1549.16,1549.16,,,,,,Dihydrotestosterone REF,82642,0300,,80.8,60.6,60.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,8013.86,6010.4,6010.4,17.19,16.31,81.11,,,,,,Beta-Hydroxybutyrate REF,82010,0300,,75.6,56.7,56.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,642,Inborn errors of metabolism,169.9,127.43,127.43,31.06,31.06,1824.52,,,,,,58160-0825-52 - hepatitis A pediatric vaccine 720 units/0.5 mL PF IM Susp (PHS) [REEV],,0250,58160-0825-52,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,644,Endocrine disorders with complications,4348.5,3261.38,3261.38,323.87,323.87,887.74,,,,,,00591-3797-30 - albuterol 0.083% Inh Sol 3 mL [REEV],J7613,0250,00591-3797-30,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,645,Endocrine disorders without complications,286.8,215.1,215.1,45.7,43.38,118.4,,,,,,60687-0346-01 - benzonatate 100 mg Cap [REEV],,0250,60687-0346-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,682,Kidney failure with major complications,8943.93,6707.95,6707.95,143.29,143.29,1902.98,,,,,,60687-0369-01 - dicyclomine 10 mg Cap [REEV],,0250,60687-0369-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,683,Kidney failure with complications,12430.68,9323.01,9323.01,0,33.75,33.75,,,,,,60687-0282-01 - azithromycin 250 mg Tab [REEV],,0250,60687-0282-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,684,Renal failure without complications,7068.59,5301.44,5301.44,17582.82,23.34,17582.82,,,,,,00781-3159-72 - OLANZapine 10 mg Pow [REEV],,0250,00781-3159-72,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,688,Kidney & urinary tract neoplasms without complications,3563,2672.25,2672.25,728.44,728.44,728.44,,,,,,70121-1049-05 - triamcinolone acetonide 40 mg/mL 1 mL Inj Susp [REEV],J3301,0250,70121-1049-05,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,689,Kidney & urinary Infection with major complications,13194.2,9895.65,9895.65,3743.23,3743.23,3743.23,,,,,,42023-0116-25 - oxytocin 10 units/mL Inj Sol [REEV],J2590,0250,42023-0116-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,5253.83,3940.37,3940.37,43.9,13.56,1256.28,,,,,,60687-0407-01 - acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [REEV],,0250,60687-0407-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,694,Urinary stones without lithotripsy and without major complications,2489.5,1867.13,1867.13,412.48,412.48,966.91,,,,,,"00713-0678-15 - nystatin Top 100,000 units/g Crm [REEV]",,0250,00713-0678-15,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,696,Kidney & urinary tract signs & symptoms without major complications,108.1,81.08,81.08,14.28,14.28,326.3,,,,,,"J7307 Pt supplied etonogestrel (contraceptive) implant system, including implant and supplies",,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,697,Urethral stricture,887.12,665.34,665.34,65.41,65.41,65.41,,,,,,"J1071 Pt Supplied Injection, testosterone cypionate, 1mg",,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,699,Other kidney & urinary tract diagnoses with complications,3652.38,2739.29,2739.29,792.76,254.17,792.76,,,,,,00223-1720-01 - SODIUM BICARBONATE 325MG TAB (5gr) [REEV],,0250,00223-1720-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,700,Other kidney & urinary tract diagnoses without complications,3271.46,2453.6,2453.6,4516.75,42.53,8584.81,,,,,,87701-0407-54 - Vitamin E 400 IU soft gel [REEV],,0250,87701-0407-54,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,726,Benign prostatic hypertrophy without major complications,2501.62,1876.22,1876.22,412.48,214.3,412.48,,,,,,00395-2662-16 - Cherry Syrup 5ml dose [REEV],,0250,00395-2662-16,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,728,Inflammation of the male reproductive system withou major complications,1702.07,1276.55,1276.55,669.67,85.21,669.67,,,,,,ED MISC TechFee,,0450,,137.9,103.425,103.425
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,730,Other male reproductive system diagnoses without complications,468.7,351.53,351.53,141.3,141.3,428.73,,,,,,ROOM/BED: Post Partum,,0720,,581.1,435.825,435.825
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,756,"Malignancy, female reproductive system without complications",332,249,249,36.83,36.83,36.83,,,,,,"63851-0501-01 - rabies vaccine, purified chick embyro cell 2.5 intl units IM Inj [REEV]",,0250,63851-0501-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,759,"Infections, female reproductive system without complications",311,233.25,233.25,162.76,162.76,231.98,,,,,,00536-3222-01 - acetaminophen 325 mg Tab [REEV],,0250,00536-3222-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,760,Menstrual & other female reproductive system disorders with major complications,311,233.25,233.25,124.22,124.22,124.22,,,,,,50383-0804-16 - codeine-promethazine 10 mg-6.25 mg/5 mL Syr [REEV],,0250,50383-0804-16,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,761,Menstrual & other female reproductive system disorders without complications,311,233.25,233.25,196.36,117.9,661.98,,,,,,63323-0346-10 - cefTRIAXone 1 g Inj [REEV],J0696,0250,63323-0346-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,776,Postpartum & post abortion diagnoses without operating room procedure,12218.97,9164.23,9164.23,228.95,228.95,837.7,,,,,,00781-3207-85 - cefTRIAXone 500 mg Inj [REEV],J0696,0250,00781-3207-85,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,777,Ectopic pregnancy,10451.3,7838.48,7838.48,2262.06,2262.06,2262.06,,,,,,00228-2127-10 - cloNIDine 0.1 mg Tab [REEV],,0250,00228-2127-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,778,Threatened abortion,653.9,490.43,490.43,20.26,20.26,46.11,,,,,,00904-5306-60 - diphenhydrAMINE 25 mg Cap [REEV],,0250,00904-5306-60,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,779,Abortion without D&C,162.2,121.65,121.65,26.64,26.64,225.23,,,,,,00641-0376-25 - diphenhydrAMINE 50 mg/mL Inj Sol [REEV],J1200,0250,00641-0376-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,780,False labor,1830.5,1372.88,1372.88,1179.69,1179.69,1179.69,,,,,,00002-8031-01 - glucagon 1 mg Inj [REEV],J1610,0250,00002-8031-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,781,Other antepartum diagnoses w medical complications,430.5,322.88,322.88,58.92,58.92,375.96,,,,,,63323-0262-01 - heparin 5000 units/mL Inj Sol [REEV],J1644,0250,63323-0262-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,782,Other antepartum diagnoses without medical complications,622.7,467.03,467.03,97.4,92.76,97.4,,,,,,55111-0683-01 - ibuprofen 600 mg Tab [REEV],,0250,55111-0683-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,795,Normal Newborn,29.9,22.43,22.43,36.01,36.01,2285.79,,,,,,00409-3795-01 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,00409-3795-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,808,Major hematol/immun diag exc sickle cell crisis & coagul with major complications,6196.74,4647.56,4647.56,1078.27,1078.27,1078.27,,,,,,25021-0701-01 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,25021-0701-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,810,Major hematol/immun diag exc sickle cell crisis & coagul without complications,104,78,78,18.04,18.04,18.04,,,,,,"69209 REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL TechFee",69209,0450,,154.4,115.8,115.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,811,Red blood cell disorders with major complications,10642.45,7981.84,7981.84,42.53,42.53,683.23,,,,,,"30320 REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL RHINOTOMY TechFees",30320,0450,,"3,525.8",2644.35,2644.35
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,812,Anemia or other red blood cell disorders without complications,9406.09,7054.57,7054.57,18.04,18.04,3834.62,,,,,,"30999 UNLISTED PROCEDURE, NOSE TechFee",30999,0450,,567.9,425.925,425.925
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,813,Coagulation disorders,8678.39,6508.79,6508.79,857.37,857.37,857.37,,,,,,"64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE TechFee",64447,0450,,"1,650.5",1237.875,1237.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,814,Reticuloendothelial & immunity disorders with major complications,412.6,309.45,309.45,95.25,95.25,95.25,,,,,,"64520 INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC) TechFee",64520,0450,,"2,108",1581,1581
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,815,Reticuloendothelial & immunity disorders with complications,2489.5,1867.13,1867.13,412.48,412.48,412.48,,,,,,"43246 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEO TechFee",43246,0450,,"4,088.1",3066.075,3066.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,816,Reticuloendothelial & immunity disorders without complications,58.5,43.88,43.88,13.75,13.75,17.19,,,,,,"49440 INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CON TechFee",49440,0450,,"4,088.1",3066.075,3066.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,2921.19,2190.89,2190.89,711.2,285.42,711.2,,,,,,"49450 REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER F TechFee",49450,0450,,"2,099.2",1574.4,1574.4
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,2723.29,2042.47,2042.47,138.23,126.71,291.53,,,,,,43762 PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC TechFee,43762,0450,,638.4,478.8,478.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,841,Lymphoma & non-acute leukemia with complications,6421.62,4816.22,4816.22,2498.75,2498.75,2498.75,,,,,,43763 PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC TechFee,43763,0450,,638.4,478.8,478.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,842,Lymphoma & non-acute leukemia without complications,109.2,81.9,81.9,13.75,13.75,130.84,,,,,,"43999 UNLISTED PROCEDURE, STOMACH TechFee",43999,0450,,"2,099.2",1574.4,1574.4
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,845,Other myeloprolif dis or poorly diff neopl diag without complications,1917.05,1437.79,1437.79,101.43,101.43,348.55,,,,,,96379 UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS TechFee,96379,0450,,104.8,78.6,78.6
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,864,Fever,165.4,124.05,124.05,87.23,87.23,344.13,,,,,,"45005 INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM TechFee",45005,0450,,"2,700.1",2025.075,2025.075
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,866,Viral illness without major complications,2386.03,1789.52,1789.52,829.47,415.75,829.47,,,,,,"46999 UNLISTED PROCEDURE, ANUS TechFee",46999,0450,,"2,052.9",1539.675,1539.675
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,867,Other infectious & parasitic diseases diagnoses with major complications,5985.04,4488.78,4488.78,1720.3,1720.3,1720.3,,,,,,"62273 INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH TechFee",62273,0450,,"1,650.5",1237.875,1237.875
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,869,Other infectious & parasitic diseases diagnoses without complications,1066.4,799.8,799.8,15.01,15.01,172.81,,,,,,"51798 MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON- TechFee",51798,0450,,154.4,115.8,115.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,872,Blood infection without major complications,12377.4,9283.05,9283.05,3838.7,3838.7,3838.7,,,,,,24385-0485-47 - calcium carbonate 500 mg Chew Tab [REEV],,0250,24385-0485-47,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,880,Acute adjustment reaction & psychosocial dysfunction [MSDRG 880],8110.83,6083.12,6083.12,78.48,78.48,679.76,,,,,,00065-0741-14 - tetracaine Ophth 0.5% Sol [REEV],,0250,00065-0741-14,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,881,Depression [MSDRG 881],3045.2,2283.9,2283.9,2380.9,2380.9,2380.9,,,,,,00703-6801-01 - medroxyPROGESTERone 150 mg/mL IM Susp [REEV],J1050,0250,00703-6801-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,882,Neuroses except depressive,1673.6,1255.2,1255.2,520.85,520.85,520.85,,,,,,00703-0031-01 - methylPREDNISolone acetate 40 mg/mL Inj Susp [REEV],J1030,0250,00703-0031-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,883,Disorders of personality & impulse control,1950.49,1462.87,1462.87,538.97,538.97,538.97,,,,,,00409-3385-13 - piperacillin-tazobactam 3 g-0.375 g IV Inj [REEV],J2543,0250,00409-3385-13,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,884,Mental disturbances and retardation [MSDRG 884],817.3,612.98,612.98,110.96,110.96,110.96,,,,,,00409-2267-20 - labetalol 5 mg/mL IV Sol [REEV],J3490,0250,00409-2267-20,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,885,Mental Illness [MSDRG 885],947.4,710.55,710.55,126.93,126.93,705.12,,,,,,63402-0512-24 - levalbuterol 0.63 mg/3 mL Inh Sol [REEV],J7614,0250,63402-0512-24,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,886,Behavioral & developmental disorders,2425.2,1818.9,1818.9,230.86,230.86,230.86,,,,,,63323-0485-26 - lidocaine 1% 20 mL MDV Inj Sol [REEV],J2001,0250,63323-0485-26,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,887,Other mental disorder diagnoses,956.2,717.15,717.15,127.96,127.96,147.98,,,,,,50383-0775-04 - lidocaine oral 2% Sol 100 mL bottle [REEV],,0250,50383-0775-04,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,897,Alcohol or Drug Abuse without rehab or major complications [MSDRG 897],4590.55,3442.91,3442.91,2177.16,814.67,2177.16,,,,,,00093-0311-01 - loperamide 2 mg Cap [REEV],,0250,00093-0311-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,914,Traumatic injury without major complications,225,168.75,168.75,120.51,114.13,336.29,,,,,,00009-0746-35 - medroxyPROGESTERone 150 mg/mL IM Susp [REEV],J1050,0250,00009-0746-35,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,915,Allergic reactions with major complications,9700.89,7275.67,7275.67,2609.05,2609.05,2609.05,,,,,,00703-7221-04 - ondansetron 2 mg/mL Inj Sol [REEV],J2405,0250,00703-7221-04,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,916,Allergic reactions without major complications,5755.84,4316.88,4316.88,127.96,127.96,430.54,,,,,,39822-5525-03 - promethazine 25 mg/mL Inj Sol [REEV],J2550,0250,39822-5525-03,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,918,Drug poisoning without complications,6285.29,4713.97,4713.97,0,815.06,815.06,,,,,,"58160-0964-12 - rabies vaccine, purified chick embyro cell 2.5 intl units IM Inj [REEV]",,0250,58160-0964-12,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,921,Complications of treatment without complications,124.7,93.53,93.53,0,1356.33,1356.33,,,,,,63323-0026-05 - sodium bicarbonate 4.2% IV Sol 5 mL [REEV],,0250,63323-0026-05,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,923,"Other injury, poisoning & toxic effect diag without major complications",366.5,274.88,274.88,1149.69,236.65,1149.69,,,,,,00409-6533-01 - vancomycin 1 g IV Inj [REEV],J3370,0250,00409-6533-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,934,Full thickness burns without skin graft,2064.5,1548.38,1548.38,2543.78,2543.78,2543.78,,,,,,00409-4332-01 - vancomycin 500 mg IV Inj [REEV],J3370,0250,00409-4332-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,935,Non-extensive burns,9054.97,6791.23,6791.23,127.96,121.56,141.96,,,,,,00143-9875-25 - amiodarone 50 mg/mL IV Sol [REEV],J0282,0250,00143-9875-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,947,Signs & symptoms with major complications,13422.45,10066.84,10066.84,65.22,65.22,462.88,,,,,,00143-9875-25 - amiodarone 50 mg/mL Sol [REEV],J0282,0250,00143-9875-25,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",9266.42,6949.82,6949.82,24.5,18.69,580.69,,,,,,60687-0402-01 - metoprolol 50 mg ER Tab [REEV],,0250,60687-0402-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,949,Aftercare with major complications,14612.64,10959.48,10959.48,42.53,42.53,42.53,,,,,,68382-0528-60 - cholestyramine 4 g Pow UD [REEV],,0250,68382-0528-60,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,950,Aftercare without complications,80133.85,60100.39,60100.39,689.32,8.7,689.32,,,,,,00904-5448-61 - pentoxifylline 400 mg ER Tab [REEV],,0250,00904-5448-61,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,51079-0753-20 - sucralfate 1 g Tab [REEV],,0250,51079-0753-20,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Institutional,Inpatient,998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,452.1,339.08,339.08,76.18,76.18,294.9,,,,,,60687-0381-94 - phytonadione 5 mg Tab [REEV],,0250,60687-0381-94,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,11200,Skin tag removal (up to and including 15 tags) [HCPCS 11200],255.8,191.85,191.85,243.6,243.6,243.6,,,,,,68084-0597-01 - NIFEdipine 30 mg ER Tab [REEV],,0250,68084-0597-01,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,11981,Drug delivery implant insertion [HCPCS 11981],442.2,331.65,331.65,226.23,141.6,226.23,,,,,,70860-0651-10 - rocuronium 10 mg/mL IV Sol [REEV],,0250,70860-0651-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,11982,Drug delivery implant removal [HCPCS 11982],189.5,142.13,142.13,250.81,161.82,250.81,,,,,,50268-0110-15 - benazepril 10 mg Tab [REEV],,0250,50268-0110-15,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],339.4,254.55,254.55,77.09,72.62,77.09,,,,,,XR Fluoroscopy Under 1 Hour,76000,0320,,635.6,476.7,476.7
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],468.7,351.53,351.53,95.52,61.63,100.1,,,,,,"Bill Only Creatinine, 24 Hr Urine MCH",82570,0300,,78.4,58.8,58.8
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,51701,Temporary bladder catheter insertion [HCPCS 51701],372.7,279.53,279.53,70.94,43.71,98.46,,,,,,63323-0186-10 - sodium chloride 0.9% Inj Sol 10 mL [REEV],,0250,63323-0186-10,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,57454,Cervix biopsy and scraping with endoscope [HCPCS 57454],807.1,605.33,605.33,248.58,196.34,248.58,,,,,,47781-0598-91 - vancomycin 500 mg IV Inj [REEV],J3370,0250,47781-0598-91,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,58100,Uterine lining biopsy [HCPCS 58100],552.5,414.38,414.38,147.47,121.93,147.47,,,,,,49281-0752-21 - tuberculin purified protein derivative 5 TU/0.1 mL ID 1 mL Sol [REEV],,0250,49281-0752-21,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,58300,Intra-uterine device (IUD) placement for pregnancy prevention [HCPCS 58300],345.2,258.9,258.9,127.36,119.97,127.36,,,,,,67457-0887-99 - medroxyPROGESTERone 150 mg/mL IM Susp [REEV],J1050,0250,67457-0887-99,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,58301,Intra-uterine device (IUD) removal for pregnancy prevention [HCPCS 58301],169.9,127.43,127.43,150.82,114.89,150.82,,,,,,70710-1377-02 - succinylcholine 20 mg/mL Inj Sol [REEV],J0330,0250,70710-1377-02,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.78,2.07,19.9,,,,,,51079-0444-20 - levothyroxine 25 mcg (0.025 mg) Tab [REEV],,0250,51079-0444-20,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.89,5.3,61.31,,,,,,SOFIA FLU AB TEST KIT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,DS NT-PROBNP RGT RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,DS HBA1C REAGENT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,5.3,5.3,5.3,,,,,,QUICKVUE INFLUENZA A+B(purple box),,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,238.21,156.33,346.97,,,,,,DS ECI TRPNIN I ES RG,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,15.77,15.77,25,,,,,,A1C-CELLULAR LVL1 2 2.0ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,59.06,36.98,63.97,,,,,,DS ECI SIGNAL REAGENT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,90750,Shingles vaccine for injection into muscle [HCPCS 90750],446.6,334.95,334.95,161.36,161.36,446.6,,,,,,CHEMBIO STAT-PAK HIV1/2 - 20T/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,BLD COL SFTY12 23GX3/4,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,80.15,45.56,141.93,,,,,,JEWETT 30CF REFR GLASS DR - 115V,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,113.7,91.42,145.6,,,,,,DS VANCOMYCIN REAGNT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,172.61,140.39,202.54,,,,,,DS VITROS VERSATIPS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,23.86,8.98,23.86,,,,,,DS ECI TSH REAGENT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,MTS A/B/D/REVRSE CARD,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,BLD COL SFTY 21GX3/4 RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,114.08,70,166.6,,,,,,MTS ANTI-IGG CARD5X20 RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,152.85,147.2,226.48,,,,,,SOFIA STREP A+ WVD RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],68.4,51.3,51.3,68.4,68.4,240.69,,,,,,DS DIRECT TIBC RGT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,DS LIPASE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,68.4,55.34,245.75,,,,,,PROFILE V 12-PANEL RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],396.6,297.45,297.45,14.35,14.35,372.57,,,,,,DS ECI CKMB RGNT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,2.53,1.39,26.3,,,,,,ORTHO VISN 7% BSA - 12X5ML/EA,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J1030,Methylprednisolone 40 mg inj [HCPCS J1030],26.3,19.73,19.73,4.94,4.94,5.92,,,,,,DS PHENYTON,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,DS DIRECT HDL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0.08,0.08,6.58,,,,,,DS ELEC REF FLD 800 - 16MLX30/CS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,26.3,5.44,26.3,,,,,,DS AMMONIA,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],26.3,19.73,19.73,1.31,1.31,26.3,,,,,,SOFIA RSV TEST KIT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],26.3,19.73,19.73,2.35,1.11,2.45,,,,,,DS DIGOXIN,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],26.3,19.73,19.73,5.39,5.39,19.43,,,,,,MTS ABD GROUPING CARD RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.29,1.1,17.76,,,,,,MTS BUFFERED GEL CARD RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],31.5,23.63,23.63,4.88,1.8,4.88,,,,,,DS ECI PSA RGNT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J7298,"Mirena, 52 mg [HCPCS J7298]",1250.3,937.73,937.73,983.29,983.29,983.29,,,,,,DS ALCOHOL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Hospital,Professional,Outpatient,J7307,Etonogestrel implant system [HCPCS J7307],628.5,471.38,471.38,628.5,628.5,628.5,,,,,,DS THEOPHYLLINE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Other Professional Setting,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,448,214.38,2255.8,,,,,,DS VTRS AMYLASE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Institutional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],11326.9,8495.18,8495.18,0,2696.69,4250.36,,,,,,DS CALIBRATOR KIT # 11,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Institutional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1721,1290.75,1290.75,1305.45,1305.45,1305.45,,,,,,MTS A/B MONO GP CARD RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Institutional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],310.8,233.1,233.1,143.9,130.46,326.4,,,,,,DS ECI FREE T4 CAL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Institutional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",310.8,233.1,233.1,0,95.48,95.48,,,,,,DS ECI CKMB CAL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Institutional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],194.3,145.73,145.73,0,73.93,98.64,,,,,,DS ECI FREE T4 RGT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,300,Anesthesia provided during esophagus and neck procedure [HCPCS 00300],139,104.25,104.25,7.22,6.45,46.89,,,,,,DS TOTAL B-HCG II RGT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,3.97,3.97,330,,,,,,AFFIRMAGEN 0.8% - 2X10ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",139,104.25,104.25,8.77,8.77,11.15,,,,,,DS ECI T3 UPTAKE CAL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,790,Anesthesia provided during procedure in upper abdomen with use of an endoscope [HCPCS 00790],139,104.25,104.25,5.29,1.97,425.11,,,,,,DS ECI MAINTENANCE PACK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,4.83,1.64,80.91,,,,,,DS SODIUM/NA+,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,5.28,1.93,464.4,,,,,,DS VITROS CHLORIDE SLD,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel procedure with endoscope [HCPCS 00813]",139,104.25,104.25,5.44,5.44,556,,,,,,DS CREATININE/IDMS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,830,Anesthesia provided during lower abdominal hernia repair [HCPCS 00830],139,104.25,104.25,4.41,1.95,28.42,,,,,,DS BUN,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,832,Anesthesia provided during middle or incisional abdominal hernia repair [HCPCS 00832],139,104.25,104.25,0,4.64,85.14,,,,,,DS GLUCOSE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,5.05,4.8,352,,,,,,DS ENZYMATIC CO2,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,851,Anesthesia provided during tying or incision of fallopian tubes using an endoscope [HCPCS 00851],139,104.25,104.25,5.74,5.72,268.49,,,,,,DS CALCIUM,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,902,Anesthesia provided during anus and rectum procedure [HCPCS 00902],139,104.25,104.25,0,6,17.45,,,,,,DS GENTAMICIN REAGNT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,920,Anesthesia provided during male genitalia procedure [HCPCS 00920],139,104.25,104.25,4.82,4.82,4.82,,,,,,DS FS CUVETTES,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,940,"Anesthesia provided during vaginal biopsy of cervix, uterine lining, or external genitalia [HCPCS 00940]",139,104.25,104.25,6.53,6.53,6.53,,,,,,DS IRON,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,952,Anesthesia provided during uterus examination using an endoscope [HCPCS 00952],139,104.25,104.25,5.79,5.79,184.83,,,,,,DS THEOPHYLLINE SLIDES,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1250,"Anesthesia provided during procedure on nerves, muscles, tendons, fascia, and bursae of upper leg [HCPCS 01250]",139,104.25,104.25,4.13,4.13,4.13,,,,,,DS ECI FERRITIN CAL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1610,"Anesthesia provided during procedure on nerves, muscles, tendons, fascia, and bursae of shoulder and underarm [HCPCS 01610]",139,104.25,104.25,5.88,5.88,5.88,,,,,,0.8% SELECTOGEN 2X10ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1620,Anesthesia provided during closed procedure on upper arm bone and shoulder joint [HCPCS 01620],139,104.25,104.25,8.1,8.1,8.1,,,,,,DS TOTAL PROTEIN,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1922,Anesthesia provided during X-ray or radiation therapy [HCPCS 01922],139,104.25,104.25,6.6,6.6,6.6,,,,,,DS POTASSIUM/K+,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1960,Anesthesia provided during vaginal delivery [HCPCS 01960],139,104.25,104.25,1.35,1.24,296.76,,,,,,ISTAT REDESIGN CHEM8+ CARTR,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1961,Anesthesia provided during cesarean delivery [HCPCS 01961],139,104.25,104.25,5.74,5.74,329.73,,,,,,DS SALICYLATE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,4.01,3.36,245.34,,,,,,DS GGT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,1968,Anesthesia provided during cesarean delivery following labor [HCPCS 01968],139,104.25,104.25,4.41,2.99,188.42,,,,,,DS CALIBRATOR KIT # 1,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,10061,Abscess incision and drainage (complicated procedure or multiple abscesses) [HCPCS 10061],638.4,478.8,478.8,327.9,176.75,327.9,,,,,,DS ALBUMIN,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,10080,Tailbone cyst incision and drainage (simple procedure) [HCPCS 10080],1554.93,1166.2,1166.2,163.67,124.85,188.49,,,,,,ESRVACTUBE 1.2ML-SAFETY,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,10120,Incision into deepest layer of skin for foreign body removal (simple procedure) [HCPCS 10120],1325.2,993.9,993.9,208.5,208.5,208.5,,,,,,DS LACTATE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11200,Skin tag removal (up to and including 15 tags) [HCPCS 11200],255.8,191.85,191.85,243.6,243.6,243.6,,,,,,DS VTRS ALK PHOSPHATASE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11400,"Removal of non-cancerous skin lesion of trunk, arms, or legs (0.5 cm or less) [HCPCS 11400]",664.9,498.68,498.68,130.15,130.15,664.9,,,,,,DS CALIBRATOR KIT # 3,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11402,"Removal of non-cancerous skin lesion of trunk, arms, or legs (1.1 to 2.0 cm) [HCPCS 11402]",739.9,554.93,554.93,183.78,69.3,251.52,,,,,,VACU 5ML LH SEP GRN RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11403,"Removal of non-cancerous skin lesion of trunk, arms, or legs (2.1 to 3.0 cm) [HCPCS 11403]",932.8,699.6,699.6,237.41,237.41,932.8,,,,,,QUICKVUE PLS MONO RAPD,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11404,"Removal of non-cancerous skin lesion of trunk, arms, or legs (3.1 to 4.0 cm) [HCPCS 11404]",830.3,622.73,622.73,260.87,195.25,260.87,,,,,,DS AST (SGOT),,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11406,"Removal of non-cancerous skin lesion of trunk, arms, or legs (over 4.0 cm) [HCPCS 11406]",1250.3,937.73,937.73,397.16,238.72,397.16,,,,,,DS ECI WASH REAGENT - 2BT/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11422,"Removal of non-cancerous skin lesion of scalp, neck, hands, feet, or genitalia (1.1 to 2.0 cm) [HCPCS 11422]",784,588,588,217.85,217.85,217.85,,,,,,DS TOTAL B-HCG II CAL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11423,"Removal of non-cancerous skin lesion of scalp, neck, hands, feet, or genitalia (2.1 to 3.0 cm) [HCPCS 11423]",797.2,597.9,597.9,250.25,250.25,250.25,,,,,,DS ECI TOTAL T4 RGT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11442,"Removal of non-cancerous skin lesion of face, ears, eyelids, nose, lips, or mouth (1.1 to 2.0 cm) [HCPCS 11442]",837.9,628.43,628.43,232.38,90.75,232.38,,,,,,DS FS MICROTIPS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11772,Tailbone cyst removal (complicated procedure) [HCPCS 11772],2802.6,2101.95,2101.95,927.28,927.28,927.28,,,,,,DS TOTAL BILIRUBIN,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,15852,Dressing change of wound other than burn with anesthesia [HCPCS 15852],166,124.5,124.5,112,112,112,,,,,,DS ALT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,21011,Tissue tumor removal beneath the skin of face and scalp (less than 2 cm) [HCPCS 21011],655.5,491.63,491.63,624.2,624.2,624.2,,,,,,DS ECI T3 UPTAKE RGT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,21552,Tissue tumor removal from beneath the skin of neck or front of chest (3 cm or greater) [HCPCS 21552],1130.4,847.8,847.8,718.36,718.36,718.36,,,,,,DS DESICCANT PACKS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,22015,Drainage of abscess of lower spine or sacrum (open procedure) [HCPCS 22015],2598.82,1949.12,1949.12,1530.56,1530.56,1530.56,,,,,,CARDIOIMMUNE XL LVL 2 3ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,23073,Tumor removal from muscle of shoulder area (5 cm or greater) [HCPCS 23073],1681.3,1260.98,1260.98,1119.43,1119.43,1119.43,,,,,,CARDIOIMMUNE XL LVL L 3ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,27339,Muscle tumor removal from thigh or knee (5 cm or greater) [HCPCS 27339],1908.2,1431.15,1431.15,1213.84,1213.84,1213.84,,,,,,ISPRPYL ALCH 70% LABCHEM - 4LT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,31500,Breathing tube insertion into windpipe cartilage with endoscope (emergent) [HCPCS 31500],139,104.25,104.25,227.35,95.08,227.35,,,,,,DS ACETOMNPHEN,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,43235,"Esophagus, stomach, and/or upper small bowel examination with endoscope for diagnosis [HCPCS 43235]",1225,918.75,918.75,99.99,99.99,99.99,,,,,,DS CALIBRATOR KIT # 29,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1340.7,1005.53,1005.53,113.12,65.83,226.6,,,,,,A1C-CELLULR LINEARITY - 5X2ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,43251,"Esophagus, stomach, and/or upper small bowel examination and removal of polyps or tumors by snare technique with endoscope [HCPCS 43251]",1471.9,1103.93,1103.93,320.64,320.64,320.64,,,,,,DS ECI FERRITIN RGT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],2617.4,1963.05,1963.05,973.08,627.82,973.08,,,,,,VACU 4ML K3EDTA LAV RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,302.2,51.74,302.2,,,,,,VACU 5ML Z SER SEP RED RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],557.9,418.43,418.43,327.9,192.01,343.2,,,,,,LQMN ASYD IMNASY LV2 - 6X5ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,416.16,168.37,416.16,,,,,,LQMN ASYD IMNASY LV1 - 6X5ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,46260,Multiple internal and external hemorrhoid groups removal [HCPCS 46260],1977.9,1483.43,1483.43,770.31,496.99,770.31,,,,,,DS CALIBRATOR KIT # 4,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,46262,Multiple internal and external hemorrhoid groups removal with removal of abnormal drainage tract from anus [HCPCS 46262],1520.9,1140.68,1140.68,894.32,894.32,894.32,,,,,,DS TRIGLYCERIDES,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,47562,Gallbladder removal with an endoscope [HCPCS 47562],2405.7,1804.28,1804.28,1065.25,1065.25,1065.25,,,,,,TROPONIN I TEST KIT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,47563,Gallbladder removal with x-ray study of bile ducts with endoscope [HCPCS 47563],2454.2,1840.65,1840.65,1159.1,1159.1,1159.1,,,,,,USB THERM W/BOTTLE PROBE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,49082,Abdominal cavity fluid drainage [HCPCS 49082],81.2,60.9,60.9,81.2,55,81.2,,,,,,DS CALIBRATOR KIT # 2,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,49250,Navel and surrounding tissue removal [HCPCS 49250],1491,1118.25,1118.25,953.53,953.53,953.53,,,,,,NTRZNE PPR 4.5-7.5 RNGE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,49322,Abdominal examination and sample of fluid or tissue removal from abdominal cavity or cyst with endoscope [HCPCS 49322],1325.2,993.9,993.9,597.7,597.7,597.7,,,,,,DS CHOLESTEROL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,49505,Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505],1904.1,1428.08,1428.08,841.81,503.48,841.81,,,,,,CONTROL DROPPER TIPS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,49507,Groin hernia repair for patient 5 years of age or older (herniated tissue that is trapped) [HCPCS 49507],2617.4,1963.05,1963.05,947.94,566.52,947.94,,,,,,DS CALIBRATOR KIT # 9,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,49653,Abdominal or navel hernia repair with endoscope (herniated tissue that is trapped) [HCPCS 49653],3339.6,2504.7,2504.7,1503.19,940.93,1503.19,,,,,,MTS DILUENT 2 PLUS 5 X 100MLM,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,766.3,79.43,766.3,,,,,,DS IMMUNO WASH FLUID,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,55040,Fluid accumulation removal in one testicle and sperm reservoir [HCPCS 55040],866.1,649.58,649.58,545.75,545.75,545.75,,,,,,CHMTRK H UASYD LVL1 15ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,57505,Cervix tissue scraping [HCPCS 57505],383.7,287.78,287.78,76.81,33.28,76.81,,,,,,CHMTRK H UASYD LVL3 15ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58120,Widening of the cervix and surgical removal of part of the lining of the uterus by scraping and scooping (non-obstetrical) [HCPCS 58120],1464.2,1098.15,1098.15,354.71,354.71,354.71,,,,,,MTS DILUENT 2 5 X 100MLMTS DI,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58558,Uterus polyp biopsy and/or removal with endoscope [HCPCS 58558],1546.9,1160.18,1160.18,370.35,370.35,370.35,,,,,,DS MICROSNS CK FLD I-II,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58561,Uterine muscle tumor removal with endoscope [HCPCS 58561],2402.4,1801.8,1801.8,573.12,573.12,573.12,,,,,,DS CK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],7445.3,5583.98,5583.98,393.81,127.52,393.81,,,,,,DS MAGNESIUM,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58605,Fallopian tubes tying or incision during same hospitalization [HCPCS 58605],1347.3,1010.48,1010.48,0,336.97,336.97,,,,,,DS ALTV 5PACK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58611,Fallopian tubes tying or incision at time of cesarean delivery or other abdominal surgery [HCPCS 58611],423.4,317.55,317.55,121.22,9.22,121.22,,,,,,DS ECI HI SAM DILA(ON) - 100W/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58615,Fallopian tubes tying by device through vagina or incision in pubic hairline [HCPCS 58615],1148.8,861.6,861.6,388.23,102.11,388.23,,,,,,BILIRBN CLB CNTL LVL3 - 5MLX6/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58662,Ovary or pelvic tumot destruction or removal with endoscope [HCPCS 58662],3077.2,2307.9,2307.9,564.75,564.75,1063.98,,,,,,LIFESIGN MI CARDIAC CONTROLS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58671,Blocking of uterine tubes by device with endoscope [HCPCS 58671],1591,1193.25,1193.25,577.59,275.86,577.59,,,,,,DS PHOSPHOROUS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,58700,Uterine tubes removal [HCPCS 58700],3084.8,2313.6,2313.6,1249.59,593.95,1249.59,,,,,,VACU 3.5 3.2% NACIT BL RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,47.48,22.99,68.3,,,,,,DS BUBC,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59151,Ovarian or tubal pregnancy removal including removal of the ovary and/or tube with endoscope [HCPCS 59151],3057.3,2292.98,2292.98,1213.28,1213.28,1213.28,,,,,,ALCHL AMMONIA MP - 3X2X3.5ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59400,Delivery of infant through uterus and vagina with obstetric care before and after delivery [HCPCS 59400],3596.4,2697.3,2697.3,3245.09,3179.83,3245.09,,,,,,SAMPLE CUP 2ML PS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,1305.45,583.91,1462.85,,,,,,DS ECI HI SAM DILB(ON) - 100W/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59410,Delivery of infant through uterus and vagina with obstetric care after delivery [HCPCS 59410],2050.7,1538.03,1538.03,1672.45,1079.04,1672.45,,,,,,ANTI-D BIOCLONE - 3X10ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59510,Delivery of infant through incision in abdomen and uterus (cesarean delivery) with obstetric care before and after delivery [HCPCS 59510],4072.7,3054.53,3054.53,3597.9,3597.9,3597.9,,,,,,CLTSWB AMSLIQ SFTWIRE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,1470.79,138.2,1470.79,,,,,,DS HBA1C CAL KIT 31,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59622,Delivery of infant through incision in abdomen and uterus (cesarean delivery) following vaginal delivery attempt with obstetric care after delivery (patient had previos cesarean delivery) [HCPCS 59622],5136.6,3852.45,3852.45,2094.19,1972.72,2094.19,,,,,,VACU 9ML Z SER RED RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,90960,Dialysis services by physician with 4 or more visits per month (20 years of age and older) [HCPCS 90960],2255.8,1691.85,1691.85,448,214.38,2255.8,,,,,,HEMOCCULT 2HOLE S-SLIDE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,90961,Dialysis services by physician with 2-3 visits per month (20 years of age and older) [HCPCS 90961],1697.9,1273.43,1273.43,1540,242.91,1540,,,,,,HYGROMETER TEMP,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,97607,Wound vac therapy (negative pressure wound therapy) per session (surface area less than or equal to 50 square cm) [HCPCS 97607],54,40.5,40.5,54,54,54,,,,,,SPINAL FLUID CTRL L2 3X3ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,97608,Wound vac therapy (negative pressure wound therapy) per session (surface area greater than 50 square cm) [HCPCS 97608],60.1,45.08,45.08,49.86,49.86,49.86,,,,,,"SPINAL FLUID CTRL L1, 3X3ML",,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,80.15,45.56,141.93,,,,,,DS CALIBRATOR KIT # 25,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,23.86,8.98,23.86,,,,,,DS URIC ACID,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,AIMTAB REDUC TAB FORENSC,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,76.8,52.38,170.1,,,,,,SAF-T HOLDER W/FEM L RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,104.76,52.53,206.9,,,,,,VISION DILUTN TRAY 16WL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,142.78,81.71,178.67,,,,,,VACU 2ML K3EDTA LAV RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],371.6,278.7,278.7,194.97,122.95,194.97,,,,,,PBI PREVANTICS SWAB 1.6ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],240.4,180.3,180.3,106.62,59.92,194.57,,,,,,VACU 4ML PULL CAP RED RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,143.9,95.05,222.03,,,,,,DS LDH,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],403.6,302.7,302.7,212.5,120.14,248.05,,,,,,SURGICUTT DEV ADULT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,41.75,22.37,41.75,,,,,,DS CALIBRATOR KIT # 5,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,76.8,39.55,134.08,,,,,,DS ECI T3 UPTAKE RV,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,41.38,31.68,51.15,,,,,,URNALSIS L2 ABNORM - 4X60ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,76.42,45.48,91.29,,,,,,URINALSIS L1 NORM - 4X60ML/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],257,192.75,192.75,109.23,99.96,130.9,,,,,,DS FS HUMIDIFICATION PACK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,139.8,114.76,176.55,,,,,,MCRTN GRD CL PL SEP LH RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99235,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235],458.7,344.03,344.03,177.83,142.98,177.83,,,,,,DS CUPS MICRO SAMPLE,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99236,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of high severity (55 minutes per day) [HCPCS 99236],568.9,426.68,426.68,228.53,191.28,228.53,,,,,,DS CALIBRATOR KIT # 8,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,76.8,59.99,274.04,,,,,,VACU 3.5ML LH SEP GRN RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,326.4,33.41,326.4,,,,,,CHEMBIO STATPAK HIV CTL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99254,Inpatient hospital consultation with consulting physician or other qualified health care professional (typically 80 minutes) [HCPCS 99254],434.4,325.8,325.8,154.82,154.82,154.82,,,,,,MTRX TLLTIP NS 250UL BLK - 500CS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],415.7,311.78,311.78,0,86.79,92.46,,,,,,VACU 4ML GLUC GREY RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,46.23,41.76,46.23,,,,,,AIMTAB KETONE TABLETS,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",333,249.75,249.75,77.17,69.22,77.17,,,,,,MICRTAINR DIPOTAS EDTA RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,101.03,77,101.03,,,,,,NESTING SMPL CUP PS - 13MM M/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,44.36,38.82,44.36,,,,,,VACU 2ML 3.2% NACIT BL RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99464,Newborn delivery and stabilization with physician attendance [HCPCS 99464],211.7,158.78,158.78,79.03,79.03,89.75,,,,,,VACU 2ML GLUC GRAY RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,91.42,91.42,145.6,,,,,,SMPL CP 0.5ML F/BECKMN CX - M/PK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,62.38,62.38,245.75,,,,,,VACU 4ML LI HEP GRN RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,101,Seizures without major complications,215.2,161.4,161.4,2316.2,63.26,2316.2,,,,,,GRAPH PAPER 6IN CIRCULAR,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,125,Other disorders of the eye without major complications,244.8,183.6,183.6,85.21,78.84,127.96,,,,,,FINNTIP 5ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,381.06,15.26,797.02,,,,,,CHART PAPER UD6282-240,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,1272.18,954.14,954.14,380.62,62.11,380.62,,,,,,HYDROCHL ACID SOL N/10 CR 4L,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,205,Other respiratory system diagnoses with major complications,77086.47,57814.85,57814.85,399.89,399.89,399.89,,,,,,VISION EVAP CAPS 10ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,313,Chest pain,1698.38,1273.79,1273.79,649.48,120.51,1434.85,,,,,,VACU 2ML PULL CAP RED RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,173.57,119.23,9860.3,,,,,,URINE RGT STRIP 2 PARM,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,7848.97,5886.73,5886.73,85.21,85.21,1228.08,,,,,,"SODIUM HYDROXIDE, 0.1 - 1 LT",,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,563,"Fractures of hip, pelvis & thigh without major complications",225,168.75,168.75,363.74,120.51,550.32,,,,,,FB MAXI TIPS 1-10ML,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,566,Other musculoskeletal system & connective tissue diagnoses without complications,225,168.75,168.75,177.35,60.22,819.69,,,,,,CLTSWB AMIES LIQ DBL,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,605,"Trauma to the skin, subcut tiss & breast without major complications",244.8,183.6,183.6,230.35,127.96,1897.14,,,,,,DS WASTE CONTANR LINER B,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,607,Minor skin disorders without major complications,21812.12,16359.09,16359.09,110.11,110.11,412.48,,,,,,DS FS CALIBRATOR 1,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,728,Inflammation of the male reproductive system withou major complications,1702.07,1276.55,1276.55,85.21,85.21,669.67,,,,,,DS RECONSTITUTN DILNT,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,730,Other male reproductive system diagnoses without complications,468.7,351.53,351.53,428.73,141.3,428.73,,,,,,ISTAT TRICONTROLS LVL1,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,914,Traumatic injury without major complications,225,168.75,168.75,177.35,114.13,336.29,,,,,,ISTAT TRICONTROLS LVL3,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,0,51.31,199.63,,,,,,VAC MLTI SMP 22X1 RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,1.28,1.28,46.3,,,,,,1250UL TIP BULK,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,62.38,62.38,245.75,,,,,,VAC TB HEMO GRY TOP6ML RX,,,,,,
BLUECROSS BLUESHIELD OF TEXAS - Medicaid,Hospital,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],68.4,51.3,51.3,0,68.4,245.75,,,,,,VAC TB HEMO GRY TOP2ML RX,,,,,,
BOON - CHAPMAN BENEFIT ADMINISTRATORS INC - Commercial-PPO,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,15.07,1.28,46.3,,,,,,RESOLV IMMER OIL HIGH VIS 16OZ,,,,,,
BOON - CHAPMAN BENEFIT ADMINISTRATORS INC - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,MEDTOX PROFILE/VERDCT NEG CTRX,,,,,,
BOON - CHAPMAN BENEFIT ADMINISTRATORS INC - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,0,62.38,245.75,,,,,,RAYON TP 6 SHAFT STL,,,,,,
BOON - CHAPMAN BENEFIT ADMINISTRATORS INC - Commercial-PPO,,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,MICRTAINER TB EXTENDR RX,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-Indemnity,,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,25,15.77,25,,,,,,"TUBE,TEST 16X100MM PS W/O RIM",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-Indemnity,,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,170.1,85.05,170.1,,,,,,"PIPETTE, TRANSFER 5ML",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-Indemnity,,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,"REAGENT, ANTI-B BIOCLONE 10ML",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-Indemnity,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,806.99,4.51,1156.79,,,,,,AHG IGG GRN 1X10ML REAGENT ORCLNL,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,80.91,1.64,80.91,,,,,,"REAGENT, ANTI-A BIOCLONE 10ML",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,58100,Uterine lining biopsy [HCPCS 58100],552.5,414.38,414.38,121.93,121.93,147.47,,,,,,"LINEARITY SET, M ICRO CV ISE 5E D/S",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,58300,Intra-uterine device (IUD) placement for pregnancy prevention [HCPCS 58300],345.2,258.9,258.9,124.92,119.97,127.36,,,,,,"BEVERAGE, GLUC TOLERANCE ORG 50GM 10OZ",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,58301,Intra-uterine device (IUD) removal for pregnancy prevention [HCPCS 58301],169.9,127.43,127.43,129.38,114.89,150.82,,,,,,SALINE .85% 20L,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,3.17,2.07,19.9,,,,,,"TEST KIT, H PYLORI GII QUICKVUE",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,7.85,5.3,61.31,,,,,,"BANDAGE, CO-FLEX COLORPK 1""",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,15.1,12.82,82,,,,,,"WATER, DEIONIZED 20L",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,15.07,1.28,46.3,,,,,,"TEST KIT, INFLUENZA A & B CLIAWAIVED",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,0,156.33,346.97,,,,,,"FLOW SENSOR, FS2",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,170.1,85.05,170.1,,,,,,"TEST, QUICKVUE INLINE STREP A",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,"TEST KIT, PREG HCG SERUM/URINECARDS QS",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,60.95,45.56,141.93,,,,,,"TEST KIT, INFLUENZA A+B QUICKVUE",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,93.83,91.42,145.6,,,,,,NOTEBOOK SPIRAL 1 SUBJECT,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,140.39,140.39,202.54,,,,,,PRINTER LEXMARK IMAGING UNIT MS810,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],281.2,210.9,210.9,185.38,185.38,251.35,,,,,,PRINTER TONER LEXMARK MS810,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.05,13.55,72.8,,,,,,"LABELS,(CERNER) THERMAL TRANSFER 4X1.5(ZEBRA)",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,76.51,62.38,245.75,,,,,,RIBBON ZEBRA(4.3x243ft),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,108.68,70,166.6,,,,,,SALT PELLET (MORTON),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,151.75,147.2,226.48,,,,,,HANDCLEANER INDUSTRIAL,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,59.75,45.48,91.29,,,,,,SOAP FOAM SYMMETRY 1250ML,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,59.99,59.99,274.04,,,,,,SANITIZER HAND SYMMETRY 1000ML,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,0,1.39,26.3,,,,,,COVER EQUIPMENT (28X22X58),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0,0.08,6.58,,,,,,FOLDER SMEAD GREEN END-TAB(AMAZON),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,PRO-STAT WHILD CHERRY PUNCH 30oz.,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.6,1.1,17.76,,,,,,ELECTRODE VALUTRODE FOAM 2 SQ.,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,316,Other circulatory system diagnoses without complications,692.6,519.45,519.45,0,120.51,448.33,,,,,,SAFETY PINS MEDIUM PKG.,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,7.21,2.44,580.94,,,,,,COTTON PREPPING BALLS(COVIDIEN),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,214.06,28.74,271.3,,,,,,PAPER CHART STRESS TESTING,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,177.53,94.25,222.4,,,,,,SUCTION CANISTER 1500ML FOR WALLMOUNT,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,177.53,94.25,191.25,,,,,,TIPS DISPOSABLE EAR (WELCH ALLYN),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",4712.1,3534.08,3534.08,2284.78,561.23,2284.78,,,,,,CURETTE EAR LOOP (RED),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,254.93,62.12,274.64,,,,,,CURETTE EAR LOOP (YELLOW),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,965.26,107.93,965.26,,,,,,CURETTE EAR LOOP (GREEN),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,529.81,166.13,529.81,,,,,,CURETTE EAR LOOP (BLUE),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,1065.48,166.13,1065.48,,,,,,SWAB TOOTHETTE(SINGLE WRAPPED),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,88.57,23.61,157.86,,,,,,NEEDLE HYPO 25 G 1,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,117.48,11.25,148.9,,,,,,STAPLES HEAVYDUTY 3/8 (SWINGLINE),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,364.52,48.41,364.52,,,,,,POST IT SUPER STICKY NOTE (3X3)MIAMI,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,60.12,2.66,76.2,,,,,,IMAGING UNIT 70C0Z50 LEXMARK,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,66.12,10.81,66.12,,,,,,"SCISSORS(OFFICE DEPO) 8""",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,91.45,8.16,104.31,,,,,,CONTROL SOLUTION (LOW) NOVA,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,248.85,18.45,315.4,,,,,,CONTROL SOLUTION (HIGH) NOVA,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,134.6,7.58,134.6,,,,,,PROBE SONEX-HL RFID-80ML,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,69.59,6,88.2,,,,,,SOLUTION 14.0MS/CM AND 7.0PH 32OZ,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,48.76,4.34,61.8,,,,,,DUO-RECORD CARD SYSTEM,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,95.71,11.52,121.3,,,,,,MINNCARE DISENFECTANT BOTTLE,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,175.71,11.99,222.7,,,,,,"STRIP,MINNCARE TEST HD RESID",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,26.56,7.24,496.86,,,,,,"STRIP,MINNCARE 1%TEST HD INDIC",,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,103.99,2.84,108.1,,,,,,PROBE COVERS TYMPANIC,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,52.43,6.8,52.43,,,,,,NEEDLE FISTULA 17GX1(HENRY SCHEIN),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,87.03,37.79,110.3,,,,,,LAMP FLUORESCENT T8 48,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,122.69,29.48,155.5,,,,,,FORM UB-04,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87522,Lab analysis to measure the amount of Hepatitis C virus [HCPCS 87522],325.3,243.98,243.98,311.89,143.13,322.55,,,,,,BLOOD COLLECTION SET 12 23GX3/4,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,122.69,29.48,155.5,,,,,,VACU 4ML GREEN TOP,,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,17.7,4.29,35.67,,,,,,LID SLOTTED ROUND (DIETARY),,,,,,
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,130.5,45.82,378.9,,,,,,"ADAPTOR,UNIVERSAL VIAL",,0270,,5,3.75,3.75
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,26.12,4.29,27.04,,,,,,HOOD DISPOSABLE LG INFANT,,0270,,44.18,33.135,33.135
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,77.89,20.12,77.89,,,,,,NASOPHARYNGEAL AIRWAY 32FR(SUB),,0270,,14.78,11.085,11.085
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,3392.66,6.15,4344.87,,,,,,TUBING OXYGEN,,0270,,5,3.75,3.75
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,753.25,166.13,1092.27,,,,,,TRAY PUNCTURE ADT 22 3 1/2,,0270,,24.11,18.0825,18.0825
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,1161.38,28.6,1161.38,,,,,,CANNULA NASAL ADULT (O2/C02) 7FT,,0270,,5.9,4.425,4.425
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,2475.42,16.26,2475.42,,,,,,GEL SILVER SILVASORB 0.25OZ (MEDLINE),,0270,,18.68,14.01,14.01
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,3197.1,20.72,3197.1,,,,,,NIPPLE SHIELD 24MM,,0270,,13.27,9.9525,9.9525
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,1156.79,4.51,1156.79,,,,,,DRESSING(SMALL) TEGADERM 2 3/8 X 2 3/4,,0270,,5,3.75,3.75
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,2785.69,29.4,2785.69,,,,,,DRESSING (LARGE) TEGADERM 4X4-3/4,,0270,,5,3.75,3.75
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,23.51,23.51,98.36,,,,,,CLIPS FILSHIE STERILE (10BX),,0270,,232.36,174.27,174.27
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,287.99,140.59,428.4,,,,,,CIRCUIT LOW FLOW (5-40L/MIN),,0270,,149.76,112.32,112.32
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,0,10.32,28.14,,,,,,KINESIO FOOT PRE CUT,,0270,,15.62,11.715,11.715
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,382.74,39.1,434.06,,,,,,BANDAGE KERLIX AMD DRESSING 100/RL,,0270,,5,3.75,3.75
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,639.73,61.48,2109.82,,,,,,LARYNGEAL MASK SIZE 1 DISPOSABLE,,0270,,15.59,11.6925,11.6925
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,419.85,50,3116.59,,,,,,LARYNGEAL MASK SZ 1.5 DISPOSABLE,,0270,,15.59,11.6925,11.6925
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,250.2,2.42,250.2,,,,,,LARYNGEAL MASK SZ 2 DISPOSABLE,,0270,,15.59,11.6925,11.6925
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,3301.98,5.83,3301.98,,,,,,LARYNGEAL MASK SZ 2.5 DISPOSABLE,,0270,,15.59,11.6925,11.6925
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,2266.54,3.22,2266.54,,,,,,LARYNGEAL MASK SZ 3 DISPOSABLE,,0270,,15.59,11.6925,11.6925
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J0360,Hydralazine hcl injection [HCPCS J0360],36,27,27,317.84,6.88,317.84,,,,,,LARYNGEAL MASK SZ 4 DISPOSABLE,,0270,,15.59,11.6925,11.6925
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,1988.65,0.68,2868.2,,,,,,LARYNGEAL MASK SZ 5 DISPOSABLE,,0270,,15.59,11.6925,11.6925
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,332.88,0.11,332.88,,,,,,BALLOON POSTPARTUM,,0270,,302.9,227.175,227.175
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,2819.66,2.1,2819.66,,,,,,BLADE MILL 00 DISP,,0270,,30.35,22.7625,22.7625
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,1162.88,5.5,1162.88,,,,,,BLADE MILL 0 DISP,,0270,,27.34,20.505,20.505
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,808.23,0.73,808.23,,,,,,BLADE MILL 1 DISP,,0270,,30.76,23.07,23.07
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,3583.7,0.95,3583.7,,,,,,BLADE MILL 2 DISP,,0270,,25.85,19.3875,19.3875
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,811.33,2.81,811.33,,,,,,BLADE MILL 3 DISP,,0270,,30.76,23.07,23.07
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,347.63,5.49,347.63,,,,,,BLADE MAC 2 DISP,,0270,,24.89,18.6675,18.6675
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,348.28,1.29,348.28,,,,,,BLADE MAC 3 DISP,,0270,,25.97,19.4775,19.4775
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,4433.9,0.02,4433.9,,,,,,BLADE MAC 4 DISP,,0270,,30.76,23.07,23.07
BOON ADMINISTRATIVE SERVICES INC-ICL 5097 - Commercial-PPO,Hospital,Institutional,Outpatient,J7633,Budesonide non-comp con [HCPCS J7633],27.7,20.78,20.78,482.83,9.12,482.83,,,,,,BLADE LoPro S2 SPECTRUM,,0270,,81.12,60.84,60.84
BOON CHAPMAN-ICL 1136 - Commercial-PPO,,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],139,104.25,104.25,71.77,1.64,80.91,,,,,,BLADE LoPro S3 SPECTRUM,,0270,,72.85,54.6375,54.6375
BOON CHAPMAN-ICL 1136 - Commercial-PPO,,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],2107,1580.25,1580.25,397.98,168.37,416.16,,,,,,BLADE LoPro S4 SPECTRUM,,0270,,72.77,54.5775,54.5775
BOON CHAPMAN-ICL 1136 - Commercial-PPO,,Professional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],157.5,118.13,118.13,124.27,51.33,124.27,,,,,,BLADE LoPro S1 SPECTRUM,,0270,,81.12,60.84,60.84
BOON CHAPMAN-ICL 1136 - Commercial-PPO,,Professional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],5574.24,4180.68,4180.68,4398.09,4398.09,4398.09,,,,,,"TUBING, NORMOTHERMIC IV",,0270,,113.64,85.23,85.23
BOON CHAPMAN-ICL 1136 - Commercial-PPO,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.05,13.55,72.8,,,,,,SPECIPAN(SUB),,0270,,5,3.75,3.75
BOON CHAPMAN-ICL 1136 - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,76.51,62.38,245.75,,,,,,SPONGE 4X4 16PLY(SUB),,0270,,5,3.75,3.75
BOON CHAPMAN-ICL 1136 - Commercial-PPO,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,117.77,70,166.6,,,,,,FASTENER ENDOTRACHEAL,,0270,,23.93,17.9475,17.9475
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,6.62,2.44,580.94,,,,,,NASOPHARYNGEAL AIRWAY 18FR 4.5M,,0270,,14.57,10.9275,10.9275
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,124.96,20.71,250.4,,,,,,NASOPHARYNGEAL AIRWAY 20FR 5.0MM,,0270,,14.59,10.9425,10.9425
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,1830,561.23,2500,,,,,,BLADE MAC MCGRATH SZ3,,0272,,21.83,16.3725,16.3725
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,347.75,137.3,401.67,,,,,,BLADE MAC MCGRATH SZ4,,0272,,21.81,16.3575,16.3575
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,161,8.49,161,,,,,,NEEDLE EPIDURAL 17GX4-1/2,,0270,,23.27,17.4525,17.4525
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,65.67,8.87,355.2,,,,,,DRESSING HYDROFERA FOAM 4X4 SINGLE USE,,0270,,18.42,13.815,13.815
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,111.21,14.4,297.7,,,,,,"TRAY, THORA/PARA 5FR NON-VALVED",,0270,,65.38,49.035,49.035
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,9.42,73.71,,,,,,SPONGE LAP 18X18(SUB),,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,25.95,2.66,76.2,,,,,,TRAP WATER (NEONATAL),,0270,,42.53,31.8975,31.8975
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,14.95,1.89,53,,,,,,TRAY TRACHEOSTOMY KIT(SUB),,0270,,6.11,4.5825,4.5825
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,62.53,6.2,81.6,,,,,,CATHETER LATEX 18FR-5CC,,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,31.83,5.44,96,,,,,,PACK OB IV,,0270,,40.89,30.6675,30.6675
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,36.27,5.81,65.1,,,,,,PAD EYE(SUB),,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,41.07,5,105.9,,,,,,NEEDLE J-TIP .25ML,,0270,,12.92,9.69,9.69
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,87.05,32.98,268.8,,,,,,KIT KNEE/HIP EQUIPMENT,,0270,,44.96,33.72,33.72
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,72.91,9.87,141.2,,,,,,KIT MIDSTREAM W/SOAP(SUB),,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,55.26,7.65,55.26,,,,,,TROCAR 8mm(MEDLINE) ENDOPATH EXCEL BLADELESS,,0270,,199.54,149.655,149.655
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,31.99,6,88.2,,,,,,DERMAL CLEANSER 8oz(ANTISEPTIC),,0270,,13.22,9.915,9.915
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,37.5,5.43,37.5,,,,,,NASOPHARYNGEAL AIRWAY 20FR (SUB),,0270,,14.55,10.9125,10.9125
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,38.5,6.79,100.4,,,,,,PERINEAL WASH BOTTLE(EMPTY)8OZ,,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,40.36,2.84,108.1,,,,,,K-Y JELLY TUBE 4OZ (MEDICHOICE),,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,24.8,6.8,52.43,,,,,,BETADINE SOLUTION 4 OZ (SUB),,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,43.87,7.27,172,,,,,,"ADAPTER,TEE",,0270,,5.2,3.9,3.9
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,110.58,6.15,4344.87,,,,,,"ADAPTER, CUFF 22MM",,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,211.22,28.6,1161.38,,,,,,SPECIMAN 24HR. URINAL(SUB),,0270,,5,3.75,3.75
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,55.5,16.26,2475.42,,,,,,24385-0998-75 - cetirizine 10 mg Tab [REEV],,0250,24385-0998-75,,,
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,218.3,68.61,524.17,,,,,,10006-0700-28 - magnesium oxide 400 mg Tab [REEV],,0250,10006-0700-28,,,
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,149.56,29.4,2785.69,,,,,,00517-1980-05 - dicyclomine 10 mg/mL Inj Sol [REEV],J0500,0250,00517-1980-05,,,
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,39.7,12.56,48.28,,,,,,56151-1612-51 - Grape Glucose Tablets [REEV],,0250,56151-1612-51,,,
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,384.9,61.48,2109.82,,,,,,CALMOSEPTINE OINTMENT 2.5OZ,,0270,,13.35,10.0125,10.0125
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,570.1,50,3116.59,,,,,,60687-0325-01 - lisinopril 10 mg Tab [REEV],,0250,60687-0325-01,,,
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,936.1,62.92,1098.7,,,,,,50268-0084-15 - amLODIPine 5 mg Tab [REEV],,0250,50268-0084-15,,,
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,0,0.68,2868.2,,,,,,50111-0787-10 - azithromycin 250 mg Tab [REEV],,0250,50111-0787-10,,,
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,J2274,Inj morphine pf epid ithc [HCPCS J2274],25,18.75,18.75,0,11,29.34,,,,,,"SUTURE, 5-0 ETHILON G695G (OWENS)",,0272,,12.55,9.4125,9.4125
BRIGHT HEALTHCARE - Commercial-Indemnity,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,0,0.95,3583.7,,,,,,36000-0047-24 - levofloxacin 500 mg/100 mL IV Sol [REEV],J1956,0250,36000-0047-24,,,
BRIGHT HEALTHCARE - Commercial-PPO,Other Professional Setting,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,355.2,8.87,355.2,,,,,,58160-0826-52 - hepatitis A adult vaccine 1440 units/mL PF IM Susp (PHS) [REEV],,0250,58160-0826-52,,,
BRIGHT HEALTHCARE - Commercial-PPO,Other Professional Setting,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,378.9,45.82,378.9,,,,,,TUBE ET EXCHANGER 6.0-8.5MM,,0270,,15.18,11.385,11.385
BRIGHT HEALTHCARE - Commercial-PPO,Other Professional Setting,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,122.5,6.15,4344.87,,,,,,PACK LMA FASTRACH MULTI,,0270,,604.5,453.375,453.375
BRIGHT HEALTHCARE - Commercial-PPO,Other Professional Setting,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,434.06,39.1,434.06,,,,,,"99211 OB Office/Outpatient Visit - Established Patient, Level 1",99211,0521,,,,
BRIGHT HEALTHCARE - Commercial-PPO,Other Professional Setting,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,769.7,50,3116.59,,,,,,59899 Global Prenatal Visit,,,,,,
BRIGHT HEALTHCARE - Commercial-PPO,Other Professional Setting,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,71.73,1.29,348.28,,,,,,"99212 OB Office/Outpatient Visit - Established Patient, Level 2 (10 min)",99212,0521,,,,
CARRIER UNKNOWN - Commercial-HMO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,11.9,1.28,46.3,,,,,,"99213 OB Office/Outpatient Visit - Established Patient, Level 3 (15 min)",99213,0521,,,,
CARRIER UNKNOWN - Commercial-HMO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.58,62.38,245.75,,,,,,"99214 OB Office/Outpatient Visit - Established Patient, Level 4 (25 min)",99214,0521,,,,
CARRIER UNKNOWN - Commercial-HMO,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,113.59,70,166.6,,,,,,"99215 OB Office/Outpatient Visit - Established Patient, Level 5 (40 min)",99215,0521,,,,
CARRIER UNKNOWN - Commercial-HMO,Hospital,Institutional,Inpatient,305,Hypertension without major complications,504.1,378.08,378.08,266.2,56.14,1006,,,,,,"99201 OB Office/Outpatient Visit - New Patient, Level 1 (10 min)",,,,,,
CARRIER UNKNOWN - Commercial-HMO,Hospital,Institutional,Inpatient,547,Connective tissue disorders without complications,499.7,374.78,374.78,59.81,46.39,582.26,,,,,,"99202 OB Office/Outpatient Visit - New Patient, Level 2 (20 min)",99202,0521,,,,
CARRIER UNKNOWN - Commercial-HMO,Hospital,Institutional,Inpatient,554,Bone diseases & arthropathies without major complications,2172.28,1629.21,1629.21,537.66,10.47,679.97,,,,,,"99203 OB Office/Outpatient Visit - New Patient, Level 3 (30 min)",99203,0521,,,,
CARRIER UNKNOWN - Commercial-HMO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,706.62,114.13,1811.75,,,,,,"99204 OB Office/Outpatient Visit - New Patient, Level 4 (45 min)",,,,,,
CARRIER UNKNOWN - Commercial-HMO,Hospital,Institutional,Inpatient,558,"Tendonitis, myositis & bursitis without major complications",4597.81,3448.36,3448.36,15.24,15.24,1106.15,,,,,,"99205 OB Office/Outpatient Visit - New Patient, Level 5 (60 min)",,,,,,
CARRIER UNKNOWN - Commercial-HMO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,0,51.31,199.63,,,,,,57896-0451-01 - senna 8.6 mg Tab [REEV],,0250,57896-0451-01,,,
CENTENE - Commercial-PPO,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,16.55,12.82,82,,,,,,00904-5313-60 - Prenatal Multivitamins with Folic Acid 0.8 mg Tab [REEV],,0250,00904-5313-60,,,
CENTENE - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,GLOVES SZ 7 N/LATEX (green box),,0270,,5.1,3.825,3.825
CENTENE - Commercial-PPO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,21.33,15.77,25,,,,,,BREATHING CIRCUIT ADULT (ANESTHESIA),,0270,,25.03,18.7725,18.7725
CENTENE - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.35,13.55,72.8,,,,,,63323-0341-29 - cefOXitin 1 g Inj [REEV],J0694,0250,63323-0341-29,,,
CENTENE - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,70860-0778-02 - prochlorperazine 5 mg/mL Inj Sol [REEV],J0780,0250,70860-0778-02,,,
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,125,Other disorders of the eye without major complications,244.8,183.6,183.6,117.46,78.84,127.96,,,,,,"59676-0340-01 - epoetin alfa 40,000 units/mL preservative-free Sol [REEV]",J0885,0250,59676-0340-01,,,
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,153,Otitis media & URI without major complications,99.3,74.48,74.48,773.43,15.26,797.02,,,,,,45802-0061-70 - bacitracin/neomycin/polymyxin B Top Oint (pkt) [REEV],,0250,45802-0061-70,,,
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,556,Signs & symptoms of musculoskeletal system & connective tissue without major complications,12410.01,9307.51,9307.51,312.92,114.13,1811.75,,,,,,68001-0246-17 - ondansetron 4 mg Dis Tab [REEV],,0250,68001-0246-17,,,
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,645,Endocrine disorders without complications,286.8,215.1,215.1,99.18,43.38,118.4,,,,,,Anesthesia Technical Fee,,0370,,110.3,82.725,82.725
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,761,Menstrual & other female reproductive system disorders without complications,311,233.25,233.25,243.55,117.9,661.98,,,,,,Anesthesia Professional Fee,,,,,,
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,864,Fever,165.4,124.05,124.05,344.13,87.23,344.13,,,,,,51672-4005-01 - carBAMazepine 200 mg Tab [REEV],,0250,51672-4005-01,,,
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",9266.42,6949.82,6949.82,87.23,18.69,580.69,,,,,,"63323-0482-26 - EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20mL [REEV]",J0171,0250,63323-0482-26,,,
CENTENE - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,59430 Postpartum care onl,59430,0521,,,,
CENTENE - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,1305.45,583.91,1462.85,,,,,,SUCTION CLOSED CATH(14F) ADULT,,0270,,28.46,21.345,21.345
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,0,2.44,580.94,,,,,,GOWN(32474) XL-XLONG,,0270,,11,8.25,8.25
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,0,8.49,161,,,,,,63323-0596-13 - glucagon 1 mg Inj [REEV],J1610,0250,63323-0596-13,,,
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,0,32.34,465.3,,,,,,47682-0223-35 - bacitracin/neomycin/polymyxin B Top Oint (pkt) [REEV],,0250,47682-0223-35,,,
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,6.15,2.66,8.7,,,,,,00641-0928-25 - promethazine 25 mg/mL Inj Sol [REEV],J2550,0250,00641-0928-25,,,
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,0,8.16,104.31,,,,,,00517-3010-25 - sterile water 10 mL Inj Sol [REEV],,0250,00517-3010-25,,,
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,0,32.98,268.8,,,,,,50268-0282-13 - dutasteride 0.5 mg Cap [REEV],,0250,50268-0282-13,,,
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,0,14.11,134.34,,,,,,00832-0310-11 - valproic acid 250 mg Cap [REEV],,0250,00832-0310-11,,,
ADVANTAGE BY SUPERIOR - Medicaid,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,257.07,61.48,2109.82,,,,,,43598-0505-30 - raloxifene 60 mg Tab [REEV],,0250,43598-0505-30,,,
CIGNA - Commercial-PPO,,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],176.4,132.3,132.3,51.36,51.36,244.8,,,,,,69452-0207-13 - calcitriol 0.25 mcg Oral Cap [REEV],,0250,69452-0207-13,,,
CIGNA - Commercial-PPO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,35.11,35.11,337.46,,,,,,00115-2622-01 - terbutaline 5 mg Tab [REEV],,0250,00115-2622-01,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,11750,Nail removal [HCPCS 11750],865.6,649.2,649.2,79.4,79.4,79.4,,,,,,00904-5928-61 - labetalol 100 mg Tab [REEV],,0250,00904-5928-61,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,20,2.44,580.94,,,,,,59762-1061-01 - atropine-diphenoxylate 0.025 mg-2.5 mg Tab [REEV],,0250,59762-1061-01,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,250.4,20.71,250.4,,,,,,60687-0341-71 - potassium chloride 20 mEq/15 mL Oral Liq [REEV],,0250,60687-0341-71,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,214.2,94.25,214.2,,,,,,DRAIN CHEST SYS (BTL),,0272,,65.57,49.1775,49.1775
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,0,180.22,3324.06,,,,,,"TRAY, IRRIGATION W/PISTON SYRINGE",,0272,,5,3.75,3.75
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,0,8.49,161,,,,,,CAPSURE 30MM,,0272,,553.15,414.8625,414.8625
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,234.2,8.87,355.2,,,,,,VENTRIO ST LARGE OVAL HERNIA PATCH,,0272,,"1,565.56",1174.17,1174.17
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,0,5.81,65.1,,,,,,"99391 VFC Preventive Evaluation, Established Pt; < 1 Yr",99391,0521,,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,50.4,4.54,50.4,,,,,,"99392 VFC Preventive Evaluation, Established Pt; 1-4 Yrs",99392,0521,,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,84,6,88.2,,,,,,"99393 VFC Preventive Evaluation, Established Pt; 5-11 Yrs",99393,0521,,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,42,3.56,42,,,,,,"99394 VFC Preventive Evaluation, Established Pt; 12-17 Yrs",99394,0521,,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,155.5,8.17,155.5,,,,,,"99395 VFC Preventive Evaluation, Established Pt; 18-39 Yrs",99395,0521,,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,165.4,45.82,378.9,,,,,,HUMIDIFIER HYGROSCOPIC CONDENSER,,,,10.08,7.56,7.56
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,105,29.48,105,,,,,,00009-0602-25 - clindamycin 150 mg/mL IV Sol [REEV],J3490,0250,00009-0602-25,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,122.5,6.15,4344.87,,,,,,"B2 Glycoprotein I Ab (IgG, IgA,IgM) REF",86146,0300,,176.4,132.3,132.3
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,235.2,4.51,1156.79,,,,,,Bill Only Drug Screen Non-DOT FSI,80307,0300,,100.4,75.3,75.3
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,TUBE FEEDING 5FR/16in,,0272,,5,3.75,3.75
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,51.36,39.1,434.06,,,,,,"SYRINGE, 20CC",,0270,,5,3.75,3.75
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,384.9,61.48,2109.82,,,,,,REEV MG Tomo Combo Charge,77063,0403,,134.5,100.875,100.875
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,0,50,3116.59,,,,,,"NEEDLE EPIDURAL 6"" 18G",,0270,,23.33,17.4975,17.4975
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,936.1,62.92,1098.7,,,,,,77333-0115-10 - calcium-vitamin D 600 mg-400 intl units oral tablet [REEV],,0250,77333-0115-10,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,1.93,0.68,2868.2,,,,,,51079-0884-20 - carbidopa-levodopa 25 mg-100 mg Tab [REEV],,0250,51079-0884-20,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,0,0.73,808.23,,,,,,70069-0101-05 - methocarbamol 100 mg/mL Inj Sol [REEV],,0250,70069-0101-05,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,4.44,1.29,348.28,,,,,,43199-0012-01 - hyoscyamine 0.125 mg Dis Tab [REEV],,0250,43199-0012-01,,,
CIGNA - Commercial-PPO,Hospital,Institutional,Outpatient,S0020,"Injection, bupivicaine hydro [HCPCS S0020]",2.5,1.88,1.88,11.2,2.93,11.2,,,,,,00904-6300-61 - carvedilol 3.125 mg Tab [REEV],,0250,00904-6300-61,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,293.43,35.11,337.46,,,,,,51079-0991-20 - traMADol 50 mg Tab [REEV],,0250,51079-0991-20,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,302.87,70.45,319.43,,,,,,68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [REEV],,0250,68084-0372-01,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,258.3,107.28,315.01,,,,,,00641-6042-25 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,00641-6042-25,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,11.85,2.44,580.94,,,,,,00054-0639-05 - methylergonovine 0.2 mg Tab [REEV],,0250,00054-0639-05,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],1179.7,884.78,884.78,668.07,494.34,1384.62,,,,,,63323-0130-11 - doxycycline 100 mg IV Inj [REEV],J3490,0250,63323-0130-11,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,135.89,20.71,250.4,,,,,,11523-1167-06 - oxymetazoline Nasal 0.05% Spry [REEV],,0250,11523-1167-06,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],262.4,196.8,196.8,148.6,109.96,166.13,,,,,,76329-1240-01 - phytonadione 1 mg/0.5 mL Inj Sol [REEV],J3430,0250,76329-1240-01,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1046.4,784.8,784.8,592.58,350.85,825.61,,,,,,Misc PT Charge,97530,0420,,131.3,98.475,98.475
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,94.25,94.25,214.2,,,,,,Unattended Electrical Therapy,97014,0420,,62.9,47.175,47.175
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,124.38,37.7,213.75,,,,,,LINE SAMPLING NEONATAL,,0270,,18.88,14.16,14.16
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,1419.02,180.22,3324.06,,,,,,KIT WATER STERILE NEBULIZER 500ML,,0272,,10.25,7.6875,7.6875
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,254.39,137.3,401.67,,,,,,NASAL CANNULA (PEDI) SALTER STYLE W/7' SUPPLY TUBE,,0270,,5,3.75,3.75
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,76.67,23.61,157.86,,,,,,PT 97010 Charge,97010,0420,,48.6,36.45,36.45
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,297.7,89.59,349.41,,,,,,PT 97140 Charge,97140,0420,,83.8,62.85,62.85
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,91.77,8.49,161,,,,,,PT 97110 Charge,97110,0420,,112.5,84.375,84.375
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,138.82,8.87,355.2,,,,,,PT 97018 Charge,97018,0420,,72.8,54.6,54.6
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,84.02,11.25,148.9,,,,,,PT 97162 Charge,97162,0420,,365,273.75,273.75
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,105.62,8.3,183.45,,,,,,PT 97116 Charge,97116,0420,,101.5,76.125,76.125
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,43,2.66,76.2,,,,,,PT 97112 Charge,97112,0420,,122.5,91.875,91.875
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,5.78,2.31,20.91,,,,,,PT 97161 Charge,97161,0420,,365,273.75,273.75
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,53.63,5.44,96,,,,,,PT 97032 Charge,97032,0420,,96,72,72
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,36.37,5.81,65.1,,,,,,NO CHARGE,,0300,,0,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,5.18,4.35,81.23,,,,,,CATHETER COUDE 12FR 5CC LUBRICIOUS COATED,,0272,,24.84,18.63,18.63
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,0,32.34,465.3,,,,,,ANESTHESIA UNITS,,,,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,66.06,8.16,104.31,,,,,,00904-1453-61 - metroNIDAZOLE 250 mg Tab [REEV],,0250,00904-1453-61,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,28.67,5.43,33.59,,,,,,67457-0516-25 - fosphenytoin (PE) 100 mg/2 mL Inj Sol [REEV],,0250,67457-0516-25,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,33.02,7.34,38.68,,,,,,Lupus Anticoagulant Reflex LC,,,,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,59.15,5,105.9,,,,,,00781-2020-01 - amoxicillin 250 mg Cap [REEV],,0250,00781-2020-01,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,73.42,7.58,134.6,,,,,,"00023-6115-01 - pancrelipase 5000 units-17,000 units-24,000 units Cap [REEV]",,0250,00023-6115-01,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,76.58,14.11,134.34,,,,,,47781-0601-91 - tranexamic acid 100 mg/mL Sol (REEV),,0250,47781-0601-91,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,87.75,14.41,153.94,,,,,,"Heavy Metals Panel, Blood REF",83655,0300,,123.5,92.625,92.625
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,78.87,9.87,141.2,,,,,,"Bartonella Henselae Abs (IgG, IgM) w/Rfx to Titers REF",86611,0300,,99.9,74.925,74.925
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,49.77,6,88.2,,,,,,"Kappa/ Lambda Light Chains, Ttl, w/ Calc U24 REF",83883,0300,,202.9,152.175,152.175
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,21.38,5.43,37.5,,,,,,CATHETER COUDE 12FR 5CC,,,,38.54,28.905,28.905
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,108.29,8.55,182.7,,,,,,00121-1190-00 - citric acid-sodium citrate 334 mg-500 mg/5 mL Sol 30ml [REEV],,0250,00121-1190-00,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,37.05,2.7,54.33,,,,,,00904-6294-61 - clopidogrel 75 mg Tab [REEV],,0250,00904-6294-61,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,41.33,5.26,76.2,,,,,,51672-2116-04 - acetaminophen 325 mg Supp [REEV],,0250,51672-2116-04,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,44.24,6.74,92.02,,,,,,LABOR RECOVERY CHARGE UP TO 2 HOURS CHARGE,,0729,,317.6,238.2,238.2
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,35,2.99,62.24,,,,,,IN LABOR CARE HOURLY CHARGE,,0729,,55.2,41.4,41.4
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,27.52,2.99,48.11,,,,,,00378-0152-01 - cloNIDine 0.1 mg Tab [REEV],,0250,00378-0152-01,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,69.69,11.93,144.95,,,,,,36000-0048-24 - levofloxacin 750 mg/150 mL IV Sol [REEV],J1956,0250,36000-0048-24,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,76.61,9.2,112.32,,,,,,ELECTRODE MRI ECG(MEDLINE),,,,5,3.75,3.75
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,42.06,6.79,100.4,,,,,,68001-0116-07 - levETIRAcetam 250 mg Tab [REEV],,0250,68001-0116-07,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,41.58,5.57,65.1,,,,,,68180-0711-60 - cefdinir 300 mg Cap [REEV],,0250,68180-0711-60,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,72.07,7.27,172,,,,,,00781-6077-61 - cefdinir 125 mg/5 mL Pow btl [REEV],,0250,00781-6077-61,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.31,45.82,378.9,,,,,,CANNULA ADULT LOFLO LINE (MRI),,,,46.73,35.0475,35.0475
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,68.92,6.15,4344.87,,,,,,CANNULA PEDIATRIC LOFLO (MRI),,,,46.73,35.0475,35.0475
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,251.26,68.61,524.17,,,,,,00409-7517-16 - dextrose 50% IV Sol 50 mL [REEV],,0250,00409-7517-16,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,113.03,29.4,2785.69,,,,,,55150-0173-01 - SUMAtriptan 6 mg/0.5 mL SubQ Sol [REEV],J3030,0250,55150-0173-01,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,22.49,12.56,48.28,,,,,,45802-0203-26 - acetaminophen 160 mg/5 mL Oral Susp [REEV],,0250,45802-0203-26,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,22.48,10.24,44.01,,,,,,63323-0162-02 - ketorolac 60 mg/2 mL (PHS) [REEV],J1885,0250,63323-0162-02,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,132.87,39.1,434.06,,,,,,76329-3301-01 - dextrose 50% IV Sol 50 mL [REEV],,0250,76329-3301-01,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,217.97,61.48,2109.82,,,,,,"Mumps Ab Panel IgG, IgM REF",86735,0300,,118.1,88.575,88.575
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,322.85,50,3116.59,,,,,,Salmonella And Shigella,87046,0300,,54.4,40.8,40.8
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,530.12,62.92,1098.7,,,,,,Cardiolipin IgG,86147,0300,,116.9,87.675,87.675
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,G0328,Fecal blood scrn immunoassay [HCPCS G0328],48.8,36.6,36.6,27.54,20.42,48.31,,,,,,Cardiolipin IgM,86147,0300,,116.9,87.675,87.675
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J1756,Iron sucrose injection [HCPCS J1756],1.44,1.08,1.08,0.84,0.63,1.44,,,,,,Protein Random Urine,84156,0300,,58.5,43.875,43.875
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],12.5,9.38,9.38,14.16,5.5,1162.88,,,,,,Calcium,82310,0300,,135.2,101.4,101.4
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,14.16,7.08,29.34,,,,,,51079-0888-20 - metoclopramide 10 mg Tab [REEV],,0250,51079-0888-20,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,7.08,0.95,3583.7,,,,,,Bartonella henselae IgM,86611,0300,,99.9,74.925,74.925
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,0,1.66,23.47,,,,,,00069-6001-25 - fosphenytoin (PE) 100 mg/2 mL Inj Sol [REEV],,0250,00069-6001-25,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],510,382.5,382.5,728.8,167.53,728.8,,,,,,"PUSH BUTTON BLOOD COLLECTION SET 25G X 3/4""X12",,,,5,3.75,3.75
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,35.22,13.55,72.8,,,,,,51079-0936-20 - terazosin 1 mg Cap [REEV],,0250,51079-0936-20,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,124.75,114.76,176.55,,,,,,76204-0200-30 - albuterol 0.083% Inh Sol 3 mL [REEV],J7613,0250,76204-0200-30,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],593.2,444.9,444.9,125.38,123.23,125.38,,,,,,63323-0284-45 - vancomycin 1 g IV Inj [REEV],J3370,0250,63323-0284-45,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99306,Initial nursing facility visit by admitting physician for problem of high severity (typically 45 minutes per day) [HCPCS 99306],759.7,569.78,569.78,159.51,159.51,159.51,,,,,,63739-0079-10 - diltiazem 30 mg Tab [REEV],,0250,63739-0079-10,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",202.9,152.18,152.18,42.53,41.76,46.23,,,,,,68084-0750-25 - hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab [REEV],,0250,68084-0750-25,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],314.3,235.73,235.73,66.42,66.42,66.64,,,,,,00904-6421-61 - acetaminophen-HYDROcodone 325 mg-10 mg Tab [REEV],,0250,00904-6421-61,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],414.6,310.95,310.95,87.72,87.72,88.11,,,,,,61703-0326-18 - pamidronate 9 mg/mL Sol [REEV],J2430,0250,61703-0326-18,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",333,249.75,249.75,69.35,69.22,77.17,,,,,,63323-0651-02 - adenosine 3 mg/mL IV Sol [REEV],J0153,0250,63323-0651-02,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99316,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, more than 30 minutes [HCPCS 99316]",481.9,361.43,361.43,101.6,100.36,101.6,,,,,,60505-6146-00 - cefepime 1 g Inj [REEV],J0692,0250,60505-6146-00,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,133.87,45.82,378.9,,,,,,00378-0257-01 - haloperidol 1 mg Tab [REEV],,0250,00378-0257-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,13.45,12.82,82,,,,,,00591-2992-39 - promethazine 25 mg Supp [REEV],,0250,00591-2992-39,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.43,1.28,46.3,,,,,,00904-6422-81 - polyethylene glycol 3350 Oral Pwdr for Recon [REEV],,0250,00904-6422-81,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,85.68,62.38,245.75,,,,,,25021-0121-20 - cefepime 1 g Inj [REEV],J0692,0250,25021-0121-20,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.44,2.44,580.94,,,,,,84403,84403,0300,,240.4,180.3,180.3
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,46050,Drainage of rectal abscess surrounding the anus (superficial) [HCPCS 46050],8128.55,6096.41,6096.41,1597.15,1597.15,1597.15,,,,,,82952,82952,0300,,38.7,29.025,29.025
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],339.6,254.7,254.7,274.89,81.5,323.4,,,,,,FILSHIE CLIP (LONG) STERISHOT II SINGLE USE APPLICATOR KIT FOR DUAL INCISION LAPAROSCOPY,,,,361.4,271.05,271.05
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,1264.43,137.3,1347.57,,,,,,FILSHIE CLIP (SHORT) STERISHOT II SINGLE USE APPLICATOR FOR MINILAPAROTOMY,,,,335.4,251.55,251.55
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,202.64,20.71,250.4,,,,,,60687-0443-01 - traZODone 50 mg Tab [REEV],,0250,60687-0443-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,1124.55,137.3,1124.55,,,,,,00904-6477-61 - donepezil 5 mg Tab [REEV],,0250,00904-6477-61,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72050,Spinal x-ray of upper spine (4 or 5 views) [HCPCS 72050],355,266.25,266.25,50.72,50.72,234.73,,,,,,60687-0139-01 - valsartan 160 mg Tab [REEV],,0250,60687-0139-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,1048.09,166.13,1107.72,,,,,,58160-0820-52 - hepatitis B pediatric vaccine 10 mcg/0.5 mL Sus (TVFC) PEDI [REEV],,0250,58160-0820-52,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",1323,992.25,992.25,1124.55,166.13,1309.77,,,,,,51672-5297-01 - promethazine 25 mg Supp [REEV],,0250,51672-5297-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,72193,"Pelvis CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 72193]",1319.8,989.85,989.85,1068.37,272.21,1068.37,,,,,,60687-0418-01 - acetaminophen-HYDROcodone 325 mg-10 mg Tab [REEV],,0250,60687-0418-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,182.07,94.25,222.4,,,,,,00641-6151-25 - HYDROmorphone 2 mg/mL Inj Sol [REEV],J1170,0250,00641-6151-25,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,180.96,33.08,182.07,,,,,,00409-3365-01 - HYDROmorphone 2 mg/mL Inj Sol [REEV],J1170,0250,00409-3365-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,191.25,94.25,191.25,,,,,,67457-0423-12 - dexamethasone 4 mg/mL 1 mL Inj Sol [REEV],J1100,0250,67457-0423-12,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,191.25,94.25,214.2,,,,,,WRIST(RIGHT)KUHL WRAP BLACK COLOR,,,,40.45,30.3375,30.3375
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,246.59,73.09,246.59,,,,,,00121-1836-05 - ibuprofen 100 mg/5 mL Oral Susp [REEV],,0250,00121-1836-05,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,191.25,94.25,191.25,,,,,,68084-0299-01 - tamsulosin 0.4 mg Oral Cap [REEV],,0250,68084-0299-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,191.25,37.7,213.75,,,,,,Lacosamide REF,80235,0300,,130,97.5,97.5
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,155.8,90,225,,,,,,Cystatin C REF,82610,0300,,85.4,64.05,64.05
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74150,"Abdominal CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74150]",1267.9,950.93,950.93,1077.72,166.13,1077.72,,,,,,Tomato (F025) IgE REF,86003,0300,,47.5,35.625,35.625
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,2970.4,180.22,3324.06,,,,,,Pork (F026) IgE REF,86003,0300,,47.5,35.625,35.625
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,2389.91,561.23,2500,,,,,,Beef (F027) IgE REF,86003,0300,,47.5,35.625,35.625
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,274.64,62.12,274.64,,,,,,Rice (F009) IgE REF,86003,0300,,47.5,35.625,35.625
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,452.78,166.13,529.3,,,,,,00168-0040-46 - betamethasone topical valerate 0.1% Cre,,0250,00168-0040-46,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,315.76,137.3,529.3,,,,,,00310-1969-30 - naloxegol 12.5 mg Tab [REEV],,0250,00310-1969-30,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,635.38,92.55,635.38,,,,,,68001-0338-62 - vancomycin 500 mg IV Inj [REEV],J3370,0250,68001-0338-62,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],309.9,232.43,232.43,202.35,22.66,204.92,,,,,,90962 HD Visit One per Month,90962,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],485.7,364.28,364.28,412.85,108.36,412.85,,,,,,90961 HD Visit 2 to 3 per Month,90961,0964,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.6,8.87,355.2,,,,,,90960 HD Visit 4 or More per Month,90960,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,75.1,43.35,182.52,,,,,,90970 HD Visit for Transient per Day,90970,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,141.8,11.25,148.9,,,,,,SPLINT T/F CHILD HIP,,,,79.73,59.7975,59.7975
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",185.3,138.98,138.98,149.94,8.3,183.45,,,,,,"Kidney Stone, w/ Urine/Saturation Calc LC 306266 LC",,,,7.1,5.325,5.325
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,240.98,14.4,297.7,,,,,,00002-8215-01 - insulin regular human recombinant 100 units/mL Inj Sol [REEV],J1815,0250,00002-8215-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,75.35,63.16,518.42,,,,,,CATHETER POWERPORT MRI 9.6FR,,,,821.18,615.885,615.885
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,0,9.42,73.71,,,,,,CATHETER CHOLANGIO M55,,,,91.5,68.625,68.625
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.19,2.66,76.2,,,,,,INTRADUCER PI93,,,,53.98,40.485,40.485
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,2.83,2.09,3.53,,,,,,BLADE SWITCH SCISSORS,,,,177.26,132.945,132.945
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,42.84,1.89,53,,,,,,PATCH KEYHOLE ROUND 8CM,,,,188.76,141.57,141.57
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,51.67,6.2,81.6,,,,,,427261,,,,195.63,146.7225,146.7225
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,2.31,2.31,20.91,,,,,,51672-1269-01 - betamethasone Top valerate 0.1% Crm [REEV],,0250,51672-1269-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,66.47,5.44,96,,,,,,63323-0325-10 - acyclovir 50 mg/mL IV Sol [REEV],J0133,0250,63323-0325-10,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,45.86,16.18,45.86,,,,,,TRANSFER NEEDLE 17Ga. -DOUBLE-ENDED NON-FILTERED,,,,5,3.75,3.75
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82465,Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465],53,39.75,39.75,42.84,4.42,42.84,,,,,,00409-7983-09 - Sodium Chloride 0.9% IV Sol 1000 mL [REEV],J7040,0250,00409-7983-09,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,29.99,5.81,65.1,,,,,,55150-0202-10 - pantoprazole 40 mg IV Inj [REEV],,0250,55150-0202-10,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,45.74,11.55,98.31,,,,,,17478-0937-05 - diltiazem 5 mg/mL IV Sol [REEV],J3490,0250,17478-0937-05,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,8.48,4.35,81.23,,,,,,99999-9999-10 - TPN SPECIAL SPECIFIC [REEV],,0250,99999-9999-10,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,15.13,12.67,98.39,,,,,,51672-5296-01 - promethazine 12.5 mg Supp [REEV],,0250,51672-5296-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,0,32.34,465.3,,,,,,00173-0696-00 - fluticasone-salmeterol 250 mcg-50 mcg Pow [REEV],,0250,00173-0696-00,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82785,Lab analysis to measure the IgE (immune system protein) level [HCPCS 82785],135.7,101.78,101.78,16.51,16.51,56.85,,,,,,J7307 Estonogestril (Nexplanon),J7307,0636,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,12.91,10.81,66.12,,,,,,"Ova And Parasites, Conc And Perm Smear REF",87177,0300,,56.8,42.6,42.6
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,4.24,2.66,8.7,,,,,,00006-4121-02 - human papillomavirus vaccine 9-valent Sus (PHS) [REEV],,0250,00006-4121-02,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,55.46,8.16,104.31,,,,,,67457-0887-01 - medroxyPROGESTERone 150 mg/mL IM Susp [REEV],J1050,0250,67457-0887-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,11.58,11.58,453.2,,,,,,36000-0008-24 - ciprofloxacin 200 mg/100 mL IV Sol [REEV],J0744,0250,36000-0008-24,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,128,9.72,190.22,,,,,,00054-3542-58 - megestrol 40 mg/mL Oral Susp [REEV],,0250,00054-3542-58,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,78.98,5,105.9,,,,,,50580-0535-01 - diphenhydrAMINE 12.5 mg/5 mL Oral Liq (bottle) [REEV],,0250,50580-0535-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,48.01,5.63,72.8,,,,,,SUTURE 2-0 PLAIN N863H,,,,9.14,6.855,6.855
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83872,Lab analysis to evaluate joint fluid [HCPCS 83872],78.4,58.8,58.8,39.39,39.39,39.39,,,,,,90962 HD visit 1 per month ProFee,90962,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],144.5,108.38,108.38,18.12,18.12,87.86,,,,,,90961 HD visit 2-3 per month ProFee,90961,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,19.44,19.44,112.66,,,,,,90960 HD visit 4 or more per month ProFee,90960,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84305,Lab analysis to measure the somatomedin (growth factor) level in plasma specimen [HCPCS 84305],311,233.25,233.25,21.33,21.33,21.33,,,,,,90970 HD visit for transient per day ProFee,90970,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,9.04,7.58,134.6,,,,,,GLOVES LG-SINGLE,,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,16.86,14.11,134.34,,,,,,BITE BLOCK ADJ STRAP,,,,5,3.75,3.75
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,31.44,4.35,39.58,,,,,,"83872 Mucin, synovial fluid (Ropes test)",83872,0300,,78.4,58.8,58.8
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],53,39.75,39.75,42.84,5.83,44.1,,,,,,89060 Crystal identification by light microscopy with or without,89060,0300,,77.2,57.9,57.9
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,148.1,14.41,153.94,,,,,,"Mumps Ab Panel IgG, IgM REF",86735,0300,,118.1,88.575,88.575
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,65.04,9.87,141.2,,,,,,"82310 PTH, Intact And Calcium REF",82310,0300,,135.2,101.4,101.4
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,17.05,17.05,191.3,,,,,,"86905 Blood typing, serologic; RBC antigens, other than ABO or Rh",86905,0300,,155.5,116.625,116.625
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,57.32,12.64,85.85,,,,,,"87070 Culture, Aerobic and Anaerobic w/Gram Stain REF",87070,0300,,99.3,74.475,74.475
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.79,6,88.2,,,,,,"87075 Culture, Aerobic and Anaerobic w/Gram Stain REF",87075,0300,,147.8,110.85,110.85
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,30.35,5.43,37.5,,,,,,"87205 Culture, Aerobic and Anaerobic w/Gram Stain REF",87205,0300,,51.9,38.925,38.925
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,182.7,8.55,182.7,,,,,,51079-0801-20 - metoprolol 50 mg Tab [REEV],,0250,51079-0801-20,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,56.27,3.6,69.6,,,,,,50268-0069-15 - amantadine 100 mg Cap [REEV],,0250,50268-0069-15,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,3.56,3.56,42,,,,,,63323-0853-25 - HYDROmorphone 2 mg/mL Inj Sol [REEV],J1170,0250,63323-0853-25,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,56.27,6.03,69.6,,,,,,SPONGE DRAIN NONWOVEN (4X4 6PLY STERILE LATEX FREE),,,,5,3.75,3.75
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,58.57,11.52,121.3,,,,,,54838-0511-80 - hyoscyamine 0.125 mg/5 mL Oral Liq (bottle) [REEV],,0250,54838-0511-80,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,16.62,16.62,74.01,,,,,,T1015,T1015,0521,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86787,Lab analysis to identify antibodies to varicella-zoster virus (chicken pox) [HCPCS 86787],148.9,111.68,111.68,71.9,10.82,90.53,,,,,,42037-0103-75 - aspirin 81 mg Oral EC Tab [REEV],,0250,42037-0103-75,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86906,Lab blood analysis for Rh phenotyping to confirm the Rh antibody [HCPCS 86906],390.3,292.73,292.73,7.78,6.51,228.22,,,,,,Storage/Handling Fee,P9059,0390,,135.2,101.4,101.4
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,9.2,9.2,112.32,,,,,,Bill Only Plasma Thawing Fee,86927,0390,,222.7,167.025,167.025
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],54.4,40.8,40.8,11.88,9.6,22.79,,,,,,76329-3339-01 - atropine 0.1 mg/mL 10 mL Inj Sol [REEV],J0461,0250,76329-3339-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,8.65,7.24,496.86,,,,,,67457-0349-10 - ampicillin-sulbactam 2 g-1 g Inj [REEV],J0295,0250,67457-0349-10,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,9.5,9.38,86.39,,,,,,GAUZE IODOFORM 1/4IN (MEDLINE),,,,6.94,5.205,5.205
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,8.1,6.79,100.4,,,,,,CUFF SINGLE LUMEN ADULT DISPOSABLE(MRI),,,,228.15,171.1125,171.1125
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,8.09,2.84,108.1,,,,,,"CUFF, SINGLE LUMEN LARGE ADULT DISPOSABLE (MRI)",,,,228.15,171.1125,171.1125
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,8.11,6.8,52.43,,,,,,Sp02 QUICK CONNECT GRIP ADULT DISP(MRI),,,,18.86,14.145,14.145
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],56.8,42.6,42.6,12.41,8.9,23.8,,,,,,RH Phenotype Ref,86906,0300,,191.9,143.925,143.925
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,10.3,7.27,172,,,,,,50268-0541-15 - metoprolol 50 mg ER Tab [REEV],,0250,50268-0541-15,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,4.29,4.29,39.3,,,,,,76329-3352-01 - sodium bicarbonate 8.4% IV Sol 50 mL [REEV],,0250,76329-3352-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],56.8,42.6,42.6,12.41,12.41,29.8,,,,,,16729-0277-30 - methotrexate 25 mg/mL preservative-free Sol,J9250,0250,16729-0277-30,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,12.03,8.17,155.5,,,,,,42023-0216-25 - ePHEDrine 50 mg/mL Sol [REEV],,0250,42023-0216-25,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,12.03,11.68,116.85,,,,,,46122-0557-05 - carbamide peroxide Otic 6.5% Sol [REEV],,0250,46122-0557-05,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,64.78,37.79,110.3,,,,,,60758-0188-05 - gentamicin ophthalmic 0.3% Sol [REEV],,0250,60758-0188-05,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],211.7,158.78,158.78,11.89,11.89,22.79,,,,,,68462-0293-01 - verapamil 180 mg ER Tab [REEV],,0250,68462-0293-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,35.22,14.12,74.6,,,,,,65862-0502-20 - amoxicillin-clavulanate 500 mg-125 mg Tab [REEV],,0250,65862-0502-20,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",342.7,257.03,257.03,11.91,11.91,22.84,,,,,,25021-0671-82 - ropivacaine 0.2% Inj Sol 100 mL [REEV],J2795,0250,25021-0671-82,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,37.67,29.48,155.5,,,,,,67457-0949-01 - heparin 5000 units/mL Inj Sol [REEV],J1644,0250,67457-0949-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,37.67,29.48,155.5,,,,,,14789-0010-02 - dicyclomine 10 mg/mL Inj Sol [REEV],J0500,0250,14789-0010-02,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,4.29,4.29,35.67,,,,,,AERO CHAMBER,,,,14.49,10.8675,10.8675
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,70.41,58.97,116.37,,,,,,'Bill Only Platelet Storage/Handling Fee',P9019,0390,,128.7,96.525,96.525
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.31,45.82,378.9,,,,,,00703-5051-03 - desmopressin 4 mcg/mL IV Sol [REEV],J2597,0250,00703-5051-03,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,35.2,29.48,105,,,,,,17238-0900-11 - fluorescein sodium ophthalmic strip [REEV],,0250,17238-0900-11,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,4.29,4.29,27.04,,,,,,68084-0875-01 - montelukast 10 mg Tab [REEV],,0250,68084-0875-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,89051,Lab analysis to measure cerebrospinal fluid cell count with a differential cell study [HCPCS 89051],78.4,58.8,58.8,39.39,39.39,39.39,,,,,,49884-0110-74 - ALPRAZolam 0.25 mg Tab UD [REEV],,0250,49884-0110-74,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,89060,Lab anaysis to identify crystals from tissue or body fluid sample [HCPCS 89060],77.2,57.9,57.9,38.79,38.79,38.79,,,,,,"TRAY,CATHETER 18FR(NON-LATEX)OWEN&MINOR",,,,35.5,26.625,26.625
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,71.95,6.15,4344.87,,,,,,"TRAY, CATHETER(NON LATEX) 16FR",,,,35.48,26.61,26.61
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],469.7,352.28,352.28,380.21,196.81,380.21,,,,,,"Mvista Histoplasma Quantitative Antigen, EIA REF",87385,0300,,36.8,27.6,27.6
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",468.7,351.53,351.53,306.27,39.27,311.42,,,,,,"Histoplasma Galactomannan Antigen, Urine REF",87385,0300,,36.8,27.6,27.6
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93926,Arteries and arterial grafts ultrasound of one leg (limited study) [HCPCS 93926],713.4,535.05,535.05,606.39,166.13,606.39,,,,,,"Histoplasma Antibody, Immunodiffusion REF",86698,0300,,38.4,28.8,28.8
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,606.39,166.13,1092.27,,,,,,Cobalt REF,83018,0300,,67.3,50.475,50.475
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,0,28.6,1161.38,,,,,,"Amino Acid Analysis, LC/MS, Urine REF",82139,0300,,51.7,38.775,38.775
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,0,16.26,2475.42,,,,,,"82570 Amino Acid Analysis, LC/MS, Urine REF",82570,0300,,51.7,38.775,38.775
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,0,68.61,524.17,,,,,,"5-Hydroxyindoleacetic Acid (5-HIAA), Random Urine REF",83497,0300,,39.6,29.7,29.7
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,0,20.72,3197.1,,,,,,51079-0690-20 - loperamide 2 mg Cap [REEV],,0250,51079-0690-20,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,4.51,4.51,1156.79,,,,,,00245-0212-01 - midodrine 5 mg Tab (PHS) [REEV],,0250,00245-0212-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,0,29.4,2785.69,,,,,,72485-0101-25 - diphenhydrAMINE 50 mg/mL Inj Sol [REEV],J1200,0250,72485-0101-25,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,0,12.56,48.28,,,,,,92507 ST INDIVIDUAL SPEECH THERAPY CHARGE,,,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,0,10.24,44.01,,,,,,RBC unit 1FSI for a 'Bill Only RBC Storage/Handling Fee',P9016,0390,,510,382.5,382.5
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,91.04,40.84,136.8,,,,,,CURETTE VACUUM 10MM (STRAIGHT),,,,13.07,9.8025,9.8025
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,67.83,23.51,98.36,,,,,,CURETTE VACUUM 11MM (STRAIGHT),,,,13.07,9.8025,9.8025
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,295.46,140.59,428.4,,,,,,00078-0659-20 - sacubitril-valsartan 24 mg-26 mg Tab UD [REEV],,0250,00078-0659-20,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,100.8,70.45,319.43,,,,,,00904-6773-61 - acetaminophen 325 mg Tab [REEV],,0250,00904-6773-61,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,111.61,2.2,117.5,,,,,,67457-0603-99 - heparin 40000 units injection [REEV],J1644,0250,67457-0603-99,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,208.08,39.1,434.06,,,,,,"Urea Nitrogen, 24-Hour Urine without Creatinine REF",84540,0300,,15.4,11.55,11.55
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,327.17,61.48,2109.82,,,,,,"QuestAssureD 25-Hydroxyvitamin D (D2, D3) REF",82306,0300,,290.1,217.575,217.575
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,488.61,50,3116.59,,,,,,44567-0245-25 - cefOXitin 1 g Inj [REEV],J0694,0250,44567-0245-25,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,891.5,62.92,1098.7,,,,,,Carnitine REF,82379,0300,,51.7,38.775,38.775
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",148.5,111.38,111.38,126.23,2.42,250.2,,,,,,Coenzyme Q10 REF,82542,0300,,66.5,49.875,49.875
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,19.64,5.83,3301.98,,,,,,Flex- Pathology Consultation REF,,0300,,0,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,19.63,7.4,19.63,,,,,,"Flex- Consult, Specimen A REF",,0300,,0,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,8.93,3.22,2266.54,,,,,,00641-6132-25 - naloxone 0.4 mg/mL Inj Sol [REEV],J2310,0250,00641-6132-25,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,4.49,0.68,2868.2,,,,,,77333-0983-10 - zinc sulfate 220 mg Cap [REEV],,0250,77333-0983-10,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,2.13,0.11,332.88,,,,,,00409-6778-05 - LORazepam 2 mg/mL Inj Sol [REEV],J2060,0250,00409-6778-05,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1160,Digoxin injection [HCPCS J1160],25,18.75,18.75,21.25,21.25,21.25,,,,,,00904-6007-61 - LORazepam 0.5 mg Tab [REEV],,0250,00904-6007-61,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,21.25,2.1,2819.66,,,,,,00121-1488-00 - guaiFENesin 100 mg/5 mL Oral Liq SF [REEV],,0250,00121-1488-00,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J1956,Levofloxacin injection [HCPCS J1956],12.5,9.38,9.38,16.47,5.5,16.47,,,,,,00378-6470-99 - scopolamine 1.5 mg Transderm ER Film [REEV],,0250,00378-6470-99,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,21.25,7.8,30.4,,,,,,Newborn Screen Self Pay REF,84030,0300,,102.6,76.95,76.95
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,10.63,5.5,14.67,,,,,,00008-0923-60 - pantoprazole 40 mg IV Inj [REEV],,0250,00008-0923-60,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,10.63,0.95,3583.7,,,,,,51754-0203-04 - verapamil 2.5 mg/mL IV Sol [REEV],,0250,51754-0203-04,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,15.41,1.72,16.28,,,,,,00143-9320-01 - labetalol 5 mg/mL IV Sol [REEV],,0250,00143-9320-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,21.25,2.81,811.33,,,,,,00904-5313-61 - Prenatal Multivitamins with Folic Acid 0.8 mg Tab [REEV],,0250,00904-5313-61,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,1.06,0.55,29.34,,,,,,44567-0701-25 - cefTRIAXone 1 g Inj [REEV],J0696,0250,44567-0701-25,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,5.42,1.29,348.28,,,,,,"49281-0631-15 - influenza virus vaccine, inactivated quadrivalent Sus [REEV]",,0250,49281-0631-15,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],20,15,15,14.68,0.84,14.68,,,,,,"49281-0405-65 - influenza virus vaccine, inactivated high-dose preservative-free trivalent Sus [REEV]",,0250,49281-0405-65,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,29.75,0.02,4433.9,,,,,,"49281-0719-10 - influenza virus vaccine, inactivated recombinant hemagglutinin quadrivalent Sol [REEV]",,0250,49281-0719-10,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,11981,Drug delivery implant insertion [HCPCS 11981],442.2,331.65,331.65,141.6,141.6,226.23,,,,,,24385-0024-65 - bismuth subsalicylate 262 mg Chew Tab [REEV],,0250,24385-0024-65,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.83,2.07,19.9,,,,,,69238-1617-03 - potassium chloride 20 mEq Oral Pwdr [REEV],,0250,69238-1617-03,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,7,5.3,61.31,,,,,,Leukemia/Lymphoma Evaluation REF,,0300,,0,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,12.82,12.82,82,,,,,,00245-5319-01 - potassium chloride 20 mEq ER Tab [REEV],,0250,00245-5319-01,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,12.82,1.28,46.3,,,,,,00517-2340-10 - iron sucrose 20 mg/mL IV Sol (PHS) [REEV],J1756,0250,00517-2340-10,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,346.97,156.33,346.97,,,,,,Remove skin tags add-on,11201,0521,,,,
CIGNA HEALTH AND LIFE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,21.25,15.77,25,,,,,,Removal of skin tags ,21931,,,,,
AETNA - Commercial-Indemnity,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,69.59,6,88.2,,,,,,63323-0466-17 - bupivacaine 0.5% PF Inj Sol 10 mL [REEV],S0020,0250,63323-0466-17,,,
AETNA - Commercial-Indemnity,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,74.56,7.24,496.86,,,,,,Cystic Fibrosis Screen REF,81220,0300,,"1,534.2",1150.65,1150.65
AETNA - Commercial-Indemnity,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,116.85,11.68,116.85,,,,,,Pancreatic Elastase-1 REF,83520,0300,,322,241.5,241.5
AETNA - Commercial-Indemnity,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,82.85,37.79,110.3,,,,,,SWAB BETAINE SINGLE USE,,,,5,3.75,3.75
AETNA - Commercial-Indemnity,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,124.27,45.82,378.9,,,,,,ColoVantage (Methylated Septin 9) REF,81327,0300,,284.3,213.225,213.225
AETNA - Commercial-Indemnity,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,96.65,6.15,4344.87,,,,,,63323-0322-94 - imipenem-cilastatin 500 mg Inj [REEV],J0743,0250,63323-0322-94,,,
AETNA - Commercial-Indemnity,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,384.9,61.48,2109.82,,,,,,Cold Hemagglutinins REF,86157,0300,,22.3,16.725,16.725
DUMMY DO NOT USE - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,13.22,1.28,46.3,,,,,,00904-6450-61 - isosorbide mononitrate ER 60 mg Tab [REEV],,0250,00904-6450-61,,,
DUMMY DO NOT USE - Commercial-PPO,Clinic,Professional,Outpatient,90688,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent) [HCPCS 90688]",25,18.75,18.75,0,15.77,25,,,,,,"FSH and LH, Pediatrics REF",83002,0300,,399.1,299.325,299.325
DUMMY DO NOT USE - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,0,13.55,72.8,,,,,,Protein C and S Activity with Reflex to Protein C and/or S Antigen REF,85303,0300,,38.3,28.725,28.725
DUMMY DO NOT USE - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,77.92,62.38,245.75,,,,,,85306 Protein C and S Activity with Reflex to Protein C and/or S Antigen REF,85306,0300,,42.4,31.8,31.8
DUMMY DO NOT USE - Commercial-PPO,Hospital,Institutional,Inpatient,951,Other factors influencing health status,731.1,548.33,548.33,87.23,51.31,199.63,,,,,,"XSense, Fragile X with Reflex and Chromosome Analysis, Blood REF",88262,0300,,"1,159.8",869.85,869.85
EBMS - Commercial-PPO,,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,15.1,12.82,82,,,,,,IGF Binding Protein-3 (IGFBP-3) REF,82397,0300,,167.6,125.7,125.7
EBMS - Commercial-PPO,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,15.07,1.28,46.3,,,,,,23155-0548-42 - ondansetron 2 mg/mL Inj Sol [REEV],J2405,0250,23155-0548-42,,,
EBMS - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,68382-0136-16 - losartan 50 mg Tab [REEV],,0250,68382-0136-16,,,
EBMS - Commercial-PPO,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,47.05,13.55,72.8,,,,,,Incision & Drainage Abscess,10061,0761,,865.8,649.35,649.35
EBMS - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,76.51,62.38,245.75,,,,,,54288-0125-30 - potassium chloride 20 mEq Oral Pwdr [REEV],,0250,54288-0125-30,,,
EBMS - Commercial-PPO,,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.6,1.1,17.76,,,,,,"57500 Biopsy, cervix, single or multiple, or loc",57500,0521,,,,
ELECTRICAL WORKE - Commercial-PPO,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,1203.3,119.23,9860.3,,,,,,"58805 Drainage, ovarian cyst, uni or bil, vaginal",58805,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,790,Anesthesia provided during procedure in upper abdomen with use of an endoscope [HCPCS 00790],139,104.25,104.25,78.43,1.97,425.11,,,,,,57288 Sling Operation for Stress Incontinence,57288,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,47563,Gallbladder removal with x-ray study of bile ducts with endoscope [HCPCS 47563],2454.2,1840.65,1840.65,0,1159.1,1159.1,,,,,,00487-9501-25 - albuterol 0.083% Inh Sol 3 mL [REEV],J7613,0250,00487-9501-25,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.82,2.07,19.9,,,,,,Red Blood Cell Antigen Typing REF,86905,0300,,155.5,116.625,116.625
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.66,5.3,61.31,,,,,,00054-8297-25 - furosemide 20 mg Tab [REEV],,0250,00054-8297-25,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,32.17,12.82,82,,,,,,44385 Endoscopic eval. Of small intestinal pouchw/ or w/o specimen(s) by brush./wash.,44385,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,12.82,1.28,46.3,,,,,,44388 Fiberoptic colonoscopy via colostomy,44388,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,50.18,36.98,63.97,,,,,,44389 Fiberoptic colonoscopy via colostomy for biopsy,44389,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,44394 Fiberoptic colonoscopy via colostomy w/ removal tumor/polyp/lesion(s) by snare,44394,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,75.62,45.56,141.93,,,,,,45381 Colonoscopy beyond splenic flexure w/ directed submucosal injection(s) any substance,45381,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,109.78,91.42,145.6,,,,,,"45382 Colonoscopy beyond splenic flexure w/ control of bleeding (eg, inj., cautery, laser, stapler)",45382,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,44.01,13.55,72.8,,,,,,45384 Colonoscopy beyond splenic flexure w/ removal tumor/polyp/lesion(s) by hot biopsy forceps/ca,45384,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,73.59,62.38,245.75,,,,,,45305 Proctosigmoidoscopy for biopsy,45305,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,109.25,70,166.6,,,,,,45308 Proctosigmoidoscopy w/ removal tumor/polyp/lesion(s) by hot biopsy forceps/ cautery,45308,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,147.2,147.2,226.48,,,,,,45309 Proctosigmoidoscopy w/ removal tumor/polyp/lesion(s) by snare,45309,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,74.6,52.38,170.1,,,,,,45315 Proctosigmoidoscopy w/ removal multi tumors / polyps / lesions by hot biopsy forceps/cautery,45315,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,69.32,52.53,206.9,,,,,,76872 Transrectal Ultrasound,76872,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],68.4,51.3,51.3,68.4,65.1,68.4,,,,,,45990 Anorectal Exam under anesthesia,45990,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],6.58,4.94,4.94,0,0.08,6.58,,,,,,"46250 Hemorrhoidectomy, external complete",46250,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,J1885,Ketorolac tromethamine inj [HCPCS J1885],26.3,19.73,19.73,0,5.44,26.3,,,,,,"46257 Hemorrhoidectomy, simple w/ fissurectomy",46257,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],26.3,19.73,19.73,1.16,1.11,2.45,,,,,,"46258 Hemorrhoidectomy w/ fistulectomy, w/ or w/o fissurectomy",46258,,,,,
EMIH-ICL 1172 - Commercial-Indemnity,,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.11,1.1,17.76,,,,,,46261 Hemorrhoidectomy w/ fissureectomy,46261,,,,,
EMPLOYEE BENEFIT SERVICES - Commercial-Indemnity,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,155.5,8.17,155.5,,,,,,"46262 Hemorrhoidectomy w/ fistulectomy, w/ or w/o fissurectomy",46262,,,,,
EMPLOYEE BENEFIT SERVICES - Commercial-Indemnity,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,102.62,45.82,378.9,,,,,,"46220 Papillectomy/excision anal skin tag, simple",46220,,,,,
EMPLOYEE BENEFIT SERVICES - Commercial-Indemnity,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,384.9,61.48,2109.82,,,,,,"46280 Surgical treatment anal fistula, complex, +/- seton",46280,,,,,
"EVERNORTH BEHAVIORAL HEALTH, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,2.44,2.44,580.94,,,,,,"46285 Surgical treatment anal fistula, second stage fistulotomy",46285,,,,,
"EVERNORTH BEHAVIORAL HEALTH, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.6,8.87,355.2,,,,,,46288 Closure of fistula w/ rectal advancement flap,46288,,,,,
"EVERNORTH BEHAVIORAL HEALTH, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,9.74,8.16,104.31,,,,,,"46606 Anoscopy, Biopsy",46606,,,,,
"EVERNORTH BEHAVIORAL HEALTH, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,9.04,7.58,134.6,,,,,,46700 Anoplasty,46700,,,,,
"EVERNORTH BEHAVIORAL HEALTH, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,16.86,14.11,134.34,,,,,,46040 I & D of ischiorectal/perirectal abscess,46040,,,,,
"EVERNORTH BEHAVIORAL HEALTH, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.79,6,88.2,,,,,,46060 I & D of ischiorectal/intramural abscess with Fistulectomy,46060,,,,,
FCE BENEFITS-ICL 1184 - Commercial-Indemnity,,Professional,Outpatient,21930,Tissue tumor removal from beneath the skin of back or flank (less than 3 cm) [HCPCS 21930],2054.9,1541.18,1541.18,614.09,614.09,614.09,,,,,,57300 Closure of rectovaginal fistula; tansanal,57300,,,,,
FCE BENEFITS-ICL 1184 - Commercial-Indemnity,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,100.8,62.38,245.75,,,,,,46750 Sphincteroplasty,46750,,,,,
FCE BENEFITS-ICL 1184 - Commercial-Indemnity,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,0,70,166.6,,,,,,46761 Levator muscle imbrication,46761,,,,,
FCE BENEFITS-ICL 1184 - Commercial-Indemnity,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,0,29.48,105,,,,,,46200 Fissureectomy w/ Sphincterotomy,46200,,,,,
FCE BENEFITS-ICL 1184 - Commercial-Indemnity,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,0,39.1,434.06,,,,,,"11471 Excision of skin & subcutaneous tissue for hidradenitis suppurativa, extensive",11471,,,,,
FCE BENEFITS-ICL 1184 - Commercial-Indemnity,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,0,61.48,2109.82,,,,,,"14001 Flap closure, large (>10cm)",14001,,,,,
FCE BENEFITS-ICL 1184 - Commercial-Indemnity,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,0,50,3116.59,,,,,,"14000 Flap closure, small (<10cm)",14000,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",225,168.75,168.75,25.34,25.34,25.34,,,,,,"21555 Flap closure, small (<10cm) Excision tumor, soft tissue, neck, subcuntaneous",21555,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",302.5,226.88,226.88,29.91,29.91,29.91,,,,,,46320 Enucleation/excision of external thrombotic hemorrhoid,46320,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,2.82,2.07,19.9,,,,,,"46945 Ligation of int. hemorrhoid, surgical suture",46945,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,6.66,5.3,61.31,,,,,,"45150 Division of stricture, rectum",45150,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],102.9,77.18,77.18,5.29,5.29,8.2,,,,,,"45190 Dest. Of rectal tumor, transanal approach",45190,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",718.4,538.8,538.8,48.73,48.73,48.73,,,,,,45905 Dilation of anal sphincter under anesth.,45905,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,12.82,1.28,46.3,,,,,,45910 Dilation of rectal stricture under anesth.,45910,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,45560 Repair of rectocele,45560,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,75.62,45.56,141.93,,,,,,46947 Stapled Hemorrhoidopexy,46947,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,109.78,91.42,145.6,,,,,,"44020 Enterotomy, Small bowel, not duodenum; for exploration/ biopsy/ foreign body",44020,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],223.9,167.93,167.93,169.35,140.39,202.54,,,,,,"44021 Enterotomy, Small bowel, not duodenum; for decompression (eg. Baker tube)",44021,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,44.01,13.55,72.8,,,,,,44110 Ex. Lesion(s) small/large bowel not req. anast./ exterioriza/ fistula/ single enterotomy,44110,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,73.59,62.38,245.75,,,,,,44111 Ex. Lesion(s) small/large bowel not req. anast./ exterioriza/ fistula/ single enterotomy Multi,44111,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,109.25,70,166.6,,,,,,44121 Enterectomy resection small intestine; each add'l resection & anastomosis,44121,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],83.8,62.85,62.85,22.45,22.45,55,,,,,,44139 Mobilization (take down) of splenic flexure with partial colectomy (w/ resec. Code),44139,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],176.4,132.3,132.3,200.69,51.36,244.8,,,,,,44140 Colectomy partial w/ anastomosis,44140,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],267,200.25,200.25,734.24,66.27,734.24,,,,,,44141 Colectomy partial w/ cecostomy or colostomy,44141,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],447.7,335.78,335.78,1744.38,428.35,1744.38,,,,,,44144 Colectomy partial w/ colost/ileost & creation mucofistula,44144,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],657.1,492.83,492.83,237.09,158.84,722.74,,,,,,"44146 Colectomy partial w/ coloproctost., w/ colost. (or ileost.)",44146,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.65,1.24,1.24,1.23,1.1,17.76,,,,,,44150 Colectomy total w/o proctectomy w/ ileostomy or ileoproctostomy,44150,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,16.1,16.1,220.5,,,,,,44158 Colectomy total w/o proctectomy w/ creation of ileal resevoir (S or J),44158,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,Hospital,Institutional,Outpatient,87339,Lab analysis by immunoassay (ELISA) to identify helicobacter pylori (GI tract bacteria) [HCPCS 87339],217.3,162.98,162.98,13,13,16,,,,,,44160 Right hemicolectomy,44160,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,24.58,20.12,77.89,,,,,,"44312 Revision of Ileostomy, simple",44312,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,117.5,2.2,117.5,,,,,,"44314 Revision of Ileostomy, complicated",44314,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,198.14,39.1,434.06,,,,,,"44340 Revision of colostomy, simple",44340,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,745.75,61.48,2109.82,,,,,,"44345 Revision of colostomy, complicated reconstruction",44345,,,,,
FCE BENEFITS-ICL 1184 - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,3116.59,50,3116.59,,,,,,44346 Revision of colostomy w/ repair of paracolostomy hernia,44346,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,2.92,2.09,3.53,,,,,,"44620 Closure of enterostomy, large/small",44620,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",92.7,69.53,69.53,0,5.3,236.82,,,,,,44604 Suture repair of colon,44604,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,56.98,35.11,337.46,,,,,,44850 Suture of mesentery,44850,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,254.8,70.45,319.43,,,,,,45110 MAY,45110,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],65.1,48.83,48.83,62,62,62,,,,,,45112 Straight colo-anal,45112,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,65.1,65.1,240.69,,,,,,45119 Colo-anal pouch,45119,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,231.95,65.1,240.69,,,,,,45113 Completion proctecotmy w/ ileal pouch,45113,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],65.1,48.83,48.83,231.95,68.4,240.69,,,,,,45505 Delorme Mucosectomy,45505,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,0,240.69,240.69,,,,,,"45130 Excision of rectal procidentia w/ anast., perineal (Altemier)",45130,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,J7307,Etonogestrel implant system [HCPCS J7307],628.5,471.38,471.38,628.5,628.5,1051.25,,,,,,"45540 Proctopexy, abdominal approach",45540,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Institutional,Outpatient,T1015,Clinic service [HCPCS T1015],105.91,79.43,79.43,245.75,240.69,245.75,,,,,,45550 roctopexy w/ sigmoid resection,45550,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,11981,Drug delivery implant insertion [HCPCS 11981],442.2,331.65,331.65,0,141.6,226.23,,,,,,44615 Intestinal stricturoplasty w/ or w/o dilation for obstruction,44615,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],19.9,14.93,14.93,18.9,2.07,19.9,,,,,,44650 Closure of enteroenteric / enterocolic fistula,44650,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,8.75,5.3,61.31,,,,,,"44661 Closure of enterovesical fistula, w/ bowel and or bladder resection",44661,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],82.8,62.1,62.1,17.38,12.82,82,,,,,,"47001 Biopsy of liver, needle",47001,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,17.36,1.28,46.3,,,,,,49215 Excision presacral or sacrococcygeal tumor,49215,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",5.3,3.98,3.98,0,5.3,5.3,,,,,,49255 Omentectomy,49255,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",5.3,3.98,3.98,0,5.3,5.3,,,,,,"49565 Repair of ventral hernia, recurrent",49565,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],408.2,306.15,306.15,156.33,156.33,346.97,,,,,,"49566 Repair of ventral hernia, recurrent, incarerated or strangulated",49566,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",69.3,51.98,51.98,37.97,36.98,63.97,,,,,,49568 Implantation of mesh or other prosthesis for incisional hernia repair,49568,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,90716,Varicella (chicken pox) vaccine for injection beneath skin [HCPCS 90716],170.1,127.58,127.58,0,85.05,170.1,,,,,,49900 Suture abd wall for evisceration/ dehisce,49900,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,90734,Meningococcus vaccine for injection into muscle [HCPCS 90734],382.9,287.18,287.18,134.02,134.02,193.88,,,,,,49905 Omental Flap,49905,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",5.3,3.98,3.98,5.3,5.19,5.3,,,,,,"44202 Lap sm bowel resection, single",44202,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,97169,Athletic training evaluation (typically 15 minutes) [HCPCS 97169],49.7,37.28,37.28,0,39.17,42.13,,,,,,"44203 Lap sm bowel resection, each add'l",44203,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],69.6,52.2,52.2,0,45.56,141.93,,,,,,44207 Lap LAR,44207,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],145.6,109.2,109.2,114.49,91.42,145.6,,,,,,44210 Lap subtotal colectomy,44210,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,13.55,13.55,72.8,,,,,,49010 Laparoscopic exploration behind abdomen,49010,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,93.5,62.38,245.75,,,,,,44188 Lap Surgical colostomy or skin level cecostomy,44188,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],166.6,124.95,124.95,132.83,70,166.6,,,,,,45402 Lap proctopexy w/ sigmoid resection,45402,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],250.4,187.8,187.8,0,147.2,226.48,,,,,,"44213 Lap mobilization (take down) of splenic flexure,with partial colectomy (w/ resec. Code)",44213,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99381,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99381],68.4,51.3,51.3,236.82,68.4,240.69,,,,,,49585 Umbilical Herniorraphy,49585,,,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99382,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99382],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,00228-2076-10 - temazepam 15 mg Cap [REEV],,0250,00228-2076-10,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],68.4,51.3,51.3,245.75,65.1,245.75,,,,,,00054-8146-22 - clotrimazole 10 mg Loz [REEV],,0250,00054-8146-22,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],68.4,51.3,51.3,245.75,55.34,245.75,,,,,,50268-0685-15 - prochlorperazine 10 mg Tab [REEV],,0250,50268-0685-15,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],68.4,51.3,51.3,245.75,65.1,245.75,,,,,,39328-0107-10 - potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab [REEV],,0250,39328-0107-10,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],68.4,51.3,51.3,245.75,68.4,245.75,,,,,,00409-7809-22 - DOPamine 1.6 mg/mL-D5W intravenous solution 250 mL [REEV],J1265,0250,00409-7809-22,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],26.3,19.73,19.73,26.3,1.39,26.3,,,,,,"COVID-19 RNA, Qualitative Real-Time RT-PCR REF",87635,0300,,285.3,213.975,213.975
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,J1050,Medroxyprogesterone acetate [HCPCS J1050],256.6,192.45,192.45,0,218.11,218.11,,,,,,68382-0138-14 - topiramate 25 mg Tab [REEV],,0250,68382-0138-14,,,
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,J7307,Etonogestrel implant system [HCPCS J7307],628.5,471.38,471.38,628.5,628.5,628.5,,,,,,"Chromosomal Microarray, Postnatal, ClariSure Oligo-SNP",81229,0300,,"3,197.3",2397.975,2397.975
FIRSTCARE - Commercial-Mut Defined,Clinic,Professional,Outpatient,T1015,Clinic service [HCPCS T1015],105.9,79.43,79.43,245.75,215.52,245.75,,,,,,69097-0122-12 - topiramate 25 mg Tab [REEV],,0250,69097-0122-12,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,354,Hernia procedures except inguinal & femoral with complications,14016.4,10512.3,10512.3,3354,3354,3354,,,,,,63323-0280-26 - furosemide 10 mg/mL 4 mL Inj Sol [REEV],J1940,0250,63323-0280-26,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,3802,Skin ulcers [Moderate Severity],18146.14,13609.61,13609.61,14083.28,14083.28,14083.28,,,,,,50268-0531-15 - metFORMIN 500 mg ER Tab [REEV],,0250,50268-0531-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,391,"Esophagitis, gastroent & misc digest disorders with major complications",19666.17,14749.63,14749.63,10409.97,87.23,10409.97,,,,,,63739-0701-10 - meloxicam 7.5 mg Tab [REEV],,0250,63739-0701-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,392,Stomach Disorder without complications,19805.11,14853.83,14853.83,9860.3,119.23,9860.3,,,,,,00254-1007-52 - albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [REEV],,0250,00254-1007-52,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5401,Cesarean delivery [Minor Severity],1162.2,871.65,871.65,9934.47,9934.47,10223.07,,,,,,00003-0893-21 - apixaban 2.5 mg Tab [REEV],,0250,00003-0893-21,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5402,Cesarean delivery [Moderate Severity],43188.08,32391.06,32391.06,12315.4,11506.32,16450.64,,,,,,46122-0322-26 - acetaminophen 160 mg/5 mL Oral Susp [REEV],,0250,46122-0322-26,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5403,Cesarean delivery [Major Severity],12365.98,9274.49,9274.49,12736.96,10410.7,12736.96,,,,,,63323-0690-44 - acetylcysteine 20% Sol 30 mL [REEV],,0250,63323-0690-44,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5412,Vaginal delivery w sterilization &/or D&C [Moderate Severity],11514.56,8635.92,8635.92,11640.49,11471.97,11640.49,,,,,,"Testosterone, Free, Bioavailable and Total, Males (Adult), Immunoassay REF",,0300,,0,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5601,Vaginal delivery [Minor Severity],581.1,435.83,435.83,3693.45,3693.45,6384.37,,,,,,82040,82040,0300,,53,39.75,39.75
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5602,Vaginal delivery [Moderate Severity],581.1,435.83,435.83,4065.03,3623.48,7272.33,,,,,,84270,84270,0300,,240.4,180.3,180.3
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5603,Vaginal delivery [Major Severity],4946.97,3710.23,3710.23,3161.21,3161.21,5095.38,,,,,,84403 - Testosterone,84403,0300,,194.1,145.575,145.575
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,5663,Other antepartum diagnoses [Major Severity],17327.79,12995.84,12995.84,1162.66,1162.66,11248.37,,,,,,62584-0988-01 - allopurinol 100 mg Tab [REEV],,0250,62584-0988-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,6343,"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond [Major Severity]",1343.64,1007.73,1007.73,1343.64,1343.64,1343.64,,,,,,NEBULIZER FILTERED,,0270,,23.46,17.595,17.595
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,6401,"Neonate birthwt >2499g, normal newborn or neonate w other problem [Minor Severity]",650.6,487.95,487.95,0,1559.04,1559.04,,,,,,60505-6142-05 - ceFAZolin 1 g Inj [REEV],J0690,0250,60505-6142-05,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Inpatient,6402,"Neonate birthwt >2499g, normal newborn or neonate w other problem [Moderate Severity]",1876.68,1407.51,1407.51,1932.98,1932.98,3273.21,,,,,,"Porphyrins, Fractionated, Plasma REF",82542,0300,,142,106.5,106.5
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],709,531.75,531.75,3102.09,55,3102.09,,,,,,"Porphyrins, Fractionated, Quantitative, Random Urine REF",84120,0300,,49.3,36.975,36.975
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,11042,Skin and tissue removal (first 20 sq cm or less) [HCPCS 11042],1355.1,1016.33,1016.33,1590.48,393.52,2894.06,,,,,,"Immunoglobulins Panel, Serum REF",,0300,,0,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",548.56,411.42,411.42,60,55,125,,,,,,82784 - IgA,82784,0300,,100.4,75.3,75.3
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",486.3,364.73,364.73,146.71,55,166.67,,,,,,82784 - IgG,82784,0300,,90.4,67.8,67.8
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",594.4,445.8,445.8,101.34,55,125,,,,,,82784 - IgM,82784,0300,,90.4,67.8,67.8
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,19020,Breast cyst incision and drainage [HCPCS 19020],4587.96,3440.97,3440.97,405.18,405.18,405.18,,,,,,00904-2725-61 - sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [REEV],,0250,00904-2725-61,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,20103,Penetrating arm or leg wound inspection [HCPCS 20103],506.9,380.18,380.18,146.71,146.71,146.71,,,,,,00338-0126-12 - insulin regular human recombinant 100unit/mL-NaCl 0.9% Sol 100mL PREMIX [REEV],J1815,0250,00338-0126-12,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],21,15.75,15.75,24.65,2.44,580.94,,,,,,50580-0412-02 - acetaminophen 500 mg Tab [REEV],,0250,50580-0412-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,44970,Appendix removal with endoscope [HCPCS 44970],11326.9,8495.18,8495.18,3095.48,2696.69,4250.36,,,,,,Immunoglobulin G Subclasses Panel REF,82784,0300,,100.4,75.3,75.3
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],3522.49,2641.87,2641.87,263.85,179.75,1202.14,,,,,,11200 Skin Tag Removal,11200,0361,,481.7,361.275,361.275
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,57505,Cervix tissue scraping [HCPCS 57505],5924.71,4443.53,4443.53,85.26,85.26,85.26,,,,,,20600 ASPI/INJ into SM Joint or BUR,20600,0361,,721.6,541.2,541.2
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],6338.06,4753.55,4753.55,0,1272.13,4240.7,,,,,,20605 ASPI/INJ into MED Joint or BURS,20605,0361,,721.6,541.2,541.2
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,58615,Fallopian tubes tying by device through vagina or incision in pubic hairline [HCPCS 58615],7095.29,5321.47,5321.47,848.61,848.61,848.61,,,,,,32551 Pleural Drainage,32551,0361,,"4,495.9",3371.925,3371.925
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,58670,Ovaries destrustion with endoscope [HCPCS 58670],9442.67,7082,7082,1338.26,1338.26,1338.26,,,,,,32554 Aspirate Pleura w/o Imaging,32554,0361,,"1,737.9",1303.425,1303.425
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],339.6,254.7,254.7,155.23,81.5,323.4,,,,,,32556 Chest Tube Insertion,32556,0361,,"4,292.7",3219.525,3219.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,59320,Cervical suture through vagina during pregnancy [HCPCS 59320],3933.62,2950.22,2950.22,1357.77,1049.53,1357.77,,,,,,82787-Immunoglobulin G Subclasses Panel REF,82787,0300,,102.6,76.95,76.95
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,59899,Unlisted maternity care and delivery procedure [HCPCS 59899],614.9,461.18,461.18,85.2,32.67,218.78,,,,,,36556 Central Line Placement,36556,0361,,"4,495.9",3371.925,3371.925
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,70160,Nasal bones x-ray taken from side to side for complete exam (minimum of 3 views) [HCPCS 70160],225,168.75,168.75,31.08,31.08,123.34,,,,,,36568 PICC Line Placement,36568,0361,,"1,737.9",1303.425,1303.425
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",1572.2,1179.15,1179.15,166.13,137.3,1347.57,,,,,,36592 Blood Draw through PICC or Central Line,36592,0361,,300.7,225.525,225.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",1313.2,984.9,984.9,183.14,73.48,1221.85,,,,,,40806 Frenulotomy/ectomy,40806,0361,,"1,217.6",913.2,913.2
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,70491,"Neck CT scan of the soft tissue of the neck with contrast to examine injury, foreign bodies, or tumors [HCPCS 70491]",1319.8,989.85,989.85,272.21,272.21,553.04,,,,,,49082 Abdominal Paracentesis w/o Imaging,49082,0361,,"2,166.3",1624.725,1624.725
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,70551,Imaging of brain by MRI without contrast [HCPCS 70551],1046.4,784.8,784.8,218.85,218.85,533.66,,,,,,49440 Insert Feeding Tube,49440,0361,,"4,292.7",3219.525,3219.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],250.4,187.8,187.8,20.71,20.71,250.4,,,,,,"51700 Bladder Irrigation, Simple",51700,0361,,647.6,485.7,485.7
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],271.3,203.48,203.48,28.74,28.74,271.3,,,,,,51701 Insert Straight Catheter,51701,0361,,300.7,225.525,225.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],225,168.75,168.75,132.8,94.25,177.23,,,,,,51702 Insert Catheter Simple (Foley),51702,0361,,300.7,225.525,225.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,71120,Breast bone x-ray (minimum of 2 views) [HCPCS 71120],225,168.75,168.75,28.06,28.06,28.06,,,,,,"51705 Change of Bladder Tube, Simple",51705,0361,,647.6,485.7,485.7
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",1323,992.25,992.25,1058.4,137.3,1124.55,,,,,,62270 Spinal Tap/Lumbar Puncture,62270,0361,,"1,722.9",1292.175,1292.175
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1412.4,1059.3,1059.3,272.21,272.21,1200.54,,,,,,62273 Epidural Blood Patch,62273,0361,,"1,722.9",1292.175,1292.175
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,72080,Spinal x-ray of junction of middle and lower spine (2 views) [HCPCS 72080],121.3,90.98,90.98,123.34,68.69,123.34,,,,,,90472 Immunization Administration each add,90472,0771,,69.6,52.2,52.2
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],225,168.75,168.75,166.13,4.41,166.13,,,,,,92588 Evoked Auditory Test Complete,92588,0470,,697.7,523.275,523.275
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",1303.2,977.4,977.4,992.88,166.13,1107.72,,,,,,96523 Port Flush,96523,0940,,151.8,113.85,113.85
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],98.2,73.65,73.65,166.13,41.14,166.13,,,,,,96900 Phototherapy,96900,0940,,92.2,69.15,69.15
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73000,"Collar bone x-ray, complete study [HCPCS 73000]",225,168.75,168.75,123.34,123.34,126.58,,,,,,59000 Amniocentesis,59000,0729,,"1,759.8",1319.85,1319.85
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],225,168.75,168.75,27.4,27.4,191.25,,,,,,59070 Amnio Infusion,59070,0729,,746.3,559.725,559.725
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],225,168.75,168.75,25.73,25.73,191.25,,,,,,59200 Insert Cervical Ripening Agent,59200,0729,,746.3,559.725,559.725
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",225,168.75,168.75,180,94.25,180,,,,,,59412 EXT Version Ante Manip,59412,0729,,"6,885.5",5164.125,5164.125
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],225,168.75,168.75,24.39,24.39,148.78,,,,,,Vitamin E (Tocopherol) REF,84446,0300,,39.2,29.4,29.4
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],225,168.75,168.75,120.28,18.85,148.78,,,,,,Intermediate Procedure,,0450,,633.5,475.125,475.125
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",225,168.75,168.75,33.08,33.08,182.07,,,,,,"54160 Circumcision, Surgical Excision other than Clamp, Device, or Dorsal Slit: Neonate",54160,0723,,"1,534",1150.5,1150.5
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],225,168.75,168.75,166.13,99,166.13,,,,,,20610 ASPI/INJ into LG Joint or BURS,20610,0361,,721.6,541.2,541.2
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],225,168.75,168.75,30.08,30.08,220.5,,,,,,Estrone. REF,82679,0300,,70,52.5,52.5
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],225,168.75,168.75,123.34,94.25,191.25,,,,,,49329 Unlisted laparoscopic procedure,49329,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73223,"Imaging of arm joint by MRI without contrast, followed by contrast [HCPCS 73223]",1974.7,1481.03,1481.03,561.23,561.23,561.23,,,,,,"12042 Repair, intermediate, wound of neck, hands, feet and/or ext. genitalia 2.6 cm - 7.5 cm",12042,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],225,168.75,168.75,35.41,35.41,222.75,,,,,,"59412 External cephalic version, with or w/o tocolysis",59412,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73551,Thighbone x-ray (single view) [HCPCS 73551],225,168.75,168.75,123.34,94.25,225,,,,,,"21554 Excision, tumor, soft tissue, neck or anterior thorax, subfascial, 5 cm or greater",21554,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],225,168.75,168.75,123.34,94.25,225,,,,,,65862-0476-01 - ramipril 5 mg Cap [REEV],,0250,65862-0476-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],225,168.75,168.75,29.4,29.4,177.53,,,,,,72578-0001-18 - doxycycline hyclate 100 mg Tab [REEV],,0250,72578-0001-18,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],225,168.75,168.75,123.34,94.25,214.2,,,,,,46122-0544-26 - loperamide 1 mg/7.5 mL Oral Liq (bottle) [REEV],,0250,46122-0544-26,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],290.1,217.58,217.58,166.13,73.09,246.59,,,,,,00143-9297-01 - dantrolene 20 mg IV Inj [REEV],,0250,00143-9297-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],225,168.75,168.75,27.06,27.06,225,,,,,,00869-0164-38 - magnesium citrate 8.85% Oral Liq 300 mL [REEV],,0250,00869-0164-38,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],225,168.75,168.75,123.34,94.25,191.25,,,,,,51862-0453-04 - cloNIDine 0.1 mg/24 hr Transderm ER Film [REEV],,0250,51862-0453-04,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],225,168.75,168.75,123.34,69.84,225,,,,,,69292-0524-01 - captopril 25 mg Tab [REEV],,0250,69292-0524-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],225,168.75,168.75,123.34,56.37,178.99,,,,,,60687-0410-94 - methylergonovine 0.2 mg Tab [REEV],,0250,60687-0410-94,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",225,168.75,168.75,123.34,37.7,213.75,,,,,,63739-0251-10 - valproic acid 250 mg Cap [REEV],,0250,63739-0251-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],225,168.75,168.75,120.28,94.25,148.78,,,,,,BAG PRESSURE(UNIFUSOR)1000cc,,,,29.57,22.1775,22.1775
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],225,168.75,168.75,123.34,90,225,,,,,,00832-1211-01 - warfarin 1 mg Tab [REEV],,0250,00832-1211-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],225,168.75,168.75,31.41,31.41,166.13,,,,,,67457-0384-99 - heparin 1000 units/mL Inj Sol (PHS) [REEV],J1642,0250,67457-0384-99,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,74022,"Abdominal x-ray, complete study including 2 or more views of abdomen and single view of chest [HCPCS 74022]",377.1,282.83,282.83,166.13,158,229.27,,,,,,"43840 Gastrorrhaphy, suture of perforated duodenal or gastric ulcer",43840,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,74150,"Abdominal CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74150]",1267.9,950.93,950.93,166.13,166.13,1077.72,,,,,,"99156 Moderate sedation, other physician, initial 15 minutes, 5/> yrs",99156,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",3693.4,2770.05,2770.05,350.85,180.22,3324.06,,,,,,COVID-19 Antibody (IgG) REF,86769,0300,,93.8,70.35,70.35
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",3922.7,2942.03,2942.03,561.23,561.23,2500,,,,,,60687-0266-21 - raloxifene 60 mg Tab [REEV],,0250,60687-0266-21,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",4712.1,3534.08,3534.08,561.23,561.23,2284.78,,,,,,68094-0231-62 - acetaminophen 160 mg/5 mL Oral Susp [REEV],,0250,68094-0231-62,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76010,"Imaging from nose to rectum for foreign body (single view, child) [HCPCS 76010]",225,168.75,168.75,123.34,123.34,123.34,,,,,,84156,84156,0300,,58.5,43.875,43.875
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],747.5,560.63,560.63,110.94,110.94,589.78,,,,,,84166,84166,0300,,233.8,175.35,175.35
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",323.1,242.33,242.33,62.12,62.12,274.64,,,,,,00904-5880-61 - diazepam 5 mg Tab [REEV],,0250,00904-5880-61,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],653.9,490.43,490.43,166.13,166.13,529.3,,,,,,44567-0802-10 - piperacillin-tazobactam 3 g-0.375 g Pow,J2543,0250,44567-0802-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],561.3,420.98,420.98,166.13,137.3,401.67,,,,,,Sars-CoV-2(COVID-19) -Total FSI,86769,0300,,93.8,70.35,70.35
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76770,Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770],653.9,490.43,490.43,107.93,107.93,965.26,,,,,,00228-2029-10 - ALPRAZolam 0.5 mg Tab [REEV],,0250,00228-2029-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],580,435,435,55.14,55.14,328.45,,,,,,58160-0818-11 - haemophilus b conjugate (PRP-T) vaccine - Pow,,0250,58160-0818-11,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",653.9,490.43,490.43,166.13,137.3,397.57,,,,,,"PACIFIER,NEW BORN UNSCENTED JOLLYPOP",,,,5,3.75,3.75
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76805,"Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]",653.9,490.43,490.43,166.13,137.3,529.3,,,,,,"SUCROSE SWEETUMS 24%, PRESERVATIVE-FREE",,,,5,3.75,3.75
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76815,"Abdominal ultrasound of pregnant uterus limited to fetal position, heart beat, and amniotic fluid volume (1 or more fetuses) [HCPCS 76815]",357.3,267.98,267.98,166.13,166.13,289.17,,,,,,00115-1911-01 - riMANTAdine 100 mg Tab [REEV],,0250,00115-1911-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],747.5,560.63,560.63,92.55,92.55,635.38,,,,,,00173-0681-01 - zanamivir 5 mg rotadisk [REEV],,0250,00173-0681-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76819,Fetal heart ultrasound and monitoring without non-stress testing [HCPCS 76819],517.2,387.9,387.9,166.13,137.3,166.13,,,,,,US OB Detailed Complete Ea Addl Gest,76812,0402,,151,113.25,113.25
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],671.5,503.63,503.63,166.13,166.13,529.81,,,,,,US OB Greater Than 14 Weeks Ea Addl Gest,76810,0402,,125.7,94.275,94.275
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",561.3,420.98,420.98,166.13,166.13,1065.48,,,,,,US OB Nuchal Measure 1st Trimest Ea Addl,76814,0402,,125.7,94.275,94.275
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],134.5,100.88,100.88,157.86,23.61,157.86,,,,,,99999-9999-11 - DO NOT USE AMIODARONE [REEV],,0250,99999-9999-11,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],297.7,223.28,223.28,349.41,89.59,349.41,,,,,,70860-0301-05 - diltiazem 5 mg/mL IV Sol [REEV],J3490,0250,70860-0301-05,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,77072,Imaging for bone age study [HCPCS 77072],452.1,339.08,339.08,21.71,21.71,166.13,,,,,,68094-0024-62 - diphenhydrAMINE 12.5 mg/5 mL Liq,,0250,68094-0024-62,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80047,"Lab analysis to measure the amount of ionized calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80047]",161,120.75,120.75,13.95,13.95,94.13,,,,,,43547-0336-10 - benazepril 10 mg Tab,,0250,43547-0336-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",161,120.75,120.75,8.6,8.49,161,,,,,,39822-4200-02 - rocuronium 10 mg/mL Sol,,0250,39822-4200-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],469.7,352.28,352.28,551.29,41.68,551.29,,,,,,43547-0347-09 - PARoxetine 10 mg Tab,,0250,43547-0347-09,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],246,184.5,184.5,10.73,8.87,355.2,,,,,,00378-9104-93 - nitroglycerin 0.2 mg/hr Fil,,0250,00378-9104-93,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80055,"Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]",155.5,116.63,116.63,182.51,43.35,182.52,,,,,,63323-0064-11 - magnesium sulfate 50% Sol,J3475,0250,63323-0064-11,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],148.9,111.68,111.68,11.25,11.25,148.9,,,,,,68094-0024-62 - diphenhydrAMINE 25mg/10mL Liq UD [REEV],Q0163,0250,68094-0024-62,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80074,"Lab analysis to measure the amount of hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody in blood specimen to evaluate acute hepatitis [HCPCS 80074]",462,346.5,346.5,48.41,48.41,364.52,,,,,,39822-4200-02 - rocuronium 10 mg/mL IV Sol dose [REEV],,0250,39822-4200-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],297.7,223.28,223.28,17.42,14.4,297.7,,,,,,68094-0250-62 - Megestrol Acetate 400mg/ 10mL SUSP [REEV],,0250,68094-0250-62,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],776.2,582.15,582.15,183.58,63.16,518.42,,,,,,17478-0450-16 - acetaminophen-hydrocodone 300 mg-10 mg/15 mL Liq,,0250,17478-0450-16,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,11.4,9.42,73.71,,,,,,59762-3719-01 - ALPRAZolam 0.25 mg Tab,,0250,59762-3719-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,11.65,9.63,285.09,,,,,,00169-1833-11 - insulin regular human recombinant 100 units/mL Sol,J1815,0250,00169-1833-11,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,80346,Lab analysis to measure the amount of benzodiazepines (1 to 12) in urine or blood specimen [HCPCS 80346],248.2,186.15,186.15,146.51,146.51,150.91,,,,,,00002-8215-01 - insulin regular human recombinant 100 units/mL Sol,J1815,0250,00002-8215-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],76.2,57.15,57.15,3.22,2.66,76.2,,,,,,47781-0585-68 - ketorolac 60 mg/2 mL Sol,J1885,0250,47781-0585-68,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,81002,Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002],32.1,24.08,24.08,2.92,2.09,3.53,,,,,,70860-0117-26 - nafcillin 2 g Inj [REEV],,0250,70860-0117-26,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],53,39.75,39.75,2.29,1.89,53,,,,,,Antithrombin III Activity REF,85300,0300,,32.8,24.6,24.6
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],81.6,61.2,61.2,8.75,6.2,81.6,,,,,,60687-0464-01 - levothyroxine 50 mcg (0.05 mg) Tab,,0250,60687-0464-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,81511,"Lab analysis of four analytes (afp, ue3, hcg [any form], dia) from maternal serum to identify the risk of fetal birth defects [HCPCS 81511]",657.1,492.83,492.83,771.24,124.73,771.24,,,,,,00409-1632-01 - vecuronium 10 mg IV Inj [REEV],,0250,00409-1632-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82010,"Lab analysis to measure the amount of ketone bodies in blood, serum, or plasma specimen [HCPCS 82010]",75.6,56.7,56.7,8.3,8.3,45.2,,,,,,55150-0209-02 - dexmedetomidine 100 mcg/mL Sol {REEV},,0250,55150-0209-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82024,Lab analysis to measure the adrenocorticotropic hormone (ACTH) level [HCPCS 82024],362.8,272.1,272.1,362.8,152.02,362.8,,,,,,50268-0098-15 - azithromycin 250 mg Tab [REEV],,0250,50268-0098-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82043,Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043],148.9,111.68,111.68,4.86,2.31,20.91,,,,,,50383-0779-33 - lactulose 10 g/15 mL Oral Syrup [REEV],,0250,50383-0779-33,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],314.3,235.73,235.73,14.09,14.09,91.91,,,,,,00002-8315-01 - insulin isophane human recombinant 100 units/mL SubQ Inj [REEV],J1815,0250,00002-8315-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82140,Lab analysis to measure the ammonia level [HCPCS 82140],137.9,103.43,103.43,137.9,14.81,137.9,,,,,,00517-2340-99 - iron sucrose 20 mg/mL IV Sol (PHS) [REEV],J1756,0250,00517-2340-99,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],311,233.25,233.25,6.58,5.44,96,,,,,,00409-1886-05 - levETIRAcetam 100 mg/mL IV Sol [REEV],J1953,0250,00409-1886-05,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82247,Lab analysis to measure the total bilirubin level [HCPCS 82247],118.1,88.58,88.58,4.22,4.22,50.4,,,,,,00409-9093-35 - fentaNYL 50 mcg/mL Sol [REEV],J3010,0250,00409-9093-35,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],118.1,88.58,88.58,4.22,4.22,71.8,,,,,,47781-0427-47 - fentaNYL 75 mcg/hr Transderm ER Film [REEV],,0250,47781-0427-47,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82274,Lab analysis to measure the amount of blood in stool specimen by fecal hemoglobin determination and immunoassay [HCPCS 82274],48.8,36.6,36.6,16.18,16.18,45.86,,,,,,00406-9000-76 - fentaNYL 100 mcg/hr Transderm ER Film [REEV],,0250,00406-9000-76,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],290.1,217.58,217.58,0,30.08,290.1,,,,,,51991-0793-06 - rivastigmine 1.5 mg Cap [REEV],,0250,51991-0793-06,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82530,Lab analysis to measure the amount of free cortisol (hormone) [HCPCS 82530],237.1,177.83,177.83,233.8,16.71,233.8,,,,,,00536-2220-75 - simethicone 40 mg/0.6 mL Oral Liq [REEV],,0250,00536-2220-75,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82533,Lab analysis to measure the amount of total cortisol (hormone) [HCPCS 82533],135.7,101.78,101.78,16.56,16.56,56.85,,,,,,"55700 Biopsy, prostate; needle or punch, single or multiple, any approach;",,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],65.1,48.83,48.83,6.62,5.81,65.1,,,,,,"TRAY, URETHRAL(14fr Sub)",,,,7.28,5.46,5.46
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],99.3,74.48,74.48,11.74,11.55,98.31,,,,,,68084-0295-21 - glipiZIDE 2.5 mg ER Tab [REEV],,0250,68084-0295-21,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],49.7,37.28,37.28,5.2,5.2,40.9,,,,,,43547-0412-09 - quinapril 20 mg Tab [REEV],,0250,43547-0412-09,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],97.1,72.83,72.83,4.35,4.35,81.23,,,,,,99999-9999-12 - progesterone 100 mg/mL Compound [REEV],J2675,0250,99999-9999-12,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82575,Lab analysis to measure the creatinine clearance in urine and blood specimens to test for kidney function [HCPCS 82575],131.3,98.48,98.48,9.62,9.62,15.68,,,,,,SUCTION CLOSED CATH 14FR(SUB),,,,21.26,15.945,15.945
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],124.7,93.53,93.53,12.67,12.67,98.39,,,,,,00023-0506-50 - ocular lubricant Sol [REEV],,0250,00023-0506-50,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",465.3,348.98,348.98,32.34,32.34,465.3,,,,,,62756-0142-01 - metFORMIN 500 mg ER Tab [REEV],,0250,62756-0142-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82672,Lab analysis to identify total estrogen [HCPCS 82672],255.8,191.85,191.85,255.8,155.53,255.8,,,,,,"Cryptococcal Antigen, Latex Screen W/ Reflex to Titer REF",86403,0300,,31.9,23.925,23.925
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82677,Lab analysis to measure the estriol (hormone) level [HCPCS 82677],167.6,125.7,125.7,20.31,20.31,40.09,,,,,,"Fungal Panel 3, ID REF",86698,0300,,634.6,475.95,475.95
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],118.1,88.58,88.58,11.45,11.45,112.4,,,,,,72266-0118-25 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,72266-0118-25,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82803,Lab analysis to measure the amount of blood gases [HCPCS 82803],293.3,219.98,219.98,26.5,26.5,223.7,,,,,,"63323-0489-27 - EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [REEV]",,0250,63323-0489-27,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],79.4,59.55,59.55,3.99,3.99,48.28,,,,,,"Sodium, Random Urine with Creatinine REF",82570,0300,,97.1,72.825,72.825
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82951,Lab analysis to measure blood glucose (sugar) tolerance (3 specimens) [HCPCS 82951],155.5,116.63,116.63,10.81,10.81,66.12,,,,,,Fungitell (1-3)-B-D-Glucan Assay REF,87449,0300,,342.7,257.025,257.025
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82952,Lab analysis to measure blood glucose (sugar) tolerance (each additional specimens beyond 3 specimens) [HCPCS 82952],38.7,29.03,29.03,38.7,3.98,38.7,,,,,,84300 - sodium urine,84300,0300,,39.7,29.775,29.775
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82962,Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962],9.2,6.9,6.9,7.05,2.66,8.7,,,,,,Aptima SARS-CoV-2 Handling REF,C9803,0300,,64.7,48.525,48.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,82977,Lab analysis to measure the glutamyltransferase (liver enzyme) level [HCPCS 82977],65.1,48.83,48.83,52.08,11.93,52.08,,,,,,58562 Hysteroscopy removal FB,58562,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",220.5,165.38,165.38,220.5,16.1,220.5,,,,,,SARS Antigen FSI,87426,0300,,110.3,82.725,82.725
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",399.1,299.33,299.33,178.6,18.83,178.6,,,,,,Bill Only Gram Stain MCH,,0300,,200,150,150
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],309.9,232.43,232.43,56.58,56.58,188.42,,,,,,CUFF NEONATAL BLOOD PRESS(G.E) SIZE-1,,,,5.67,4.2525,4.2525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],115.9,86.93,86.93,8.16,8.16,104.31,,,,,,CUFF NEONATAL BLOOD PRESS(G.E) SIZE-2,,,,5.67,4.2525,4.2525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],453.2,339.9,339.9,352.8,11.58,453.2,,,,,,CUFF NEONATAL BLOOD PRESS(G.E) SIZE-3,,,,5.67,4.2525,4.2525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83519,Lab analysis to measure the amount of substance by radioimmunoassay [HCPCS 83519],931.7,698.78,698.78,15.46,15.46,100.28,,,,,,CUFF NEONATAL BLOOD PRESS(G.E) SIZE-4,,,,5.67,4.2525,4.2525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],50.8,38.1,38.1,8.69,5.43,33.59,,,,,,CUFF NEONATAL BLOOD PRESS(G.E) SIZE-5,,,,5.67,4.2525,4.2525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],58.5,43.88,43.88,11.74,7.34,38.68,,,,,,Epstein-Barr Virus Antibody Panel REF,86665,0300,,151.1,113.325,113.325
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",194.1,145.58,145.58,11.76,9.72,190.22,,,,,,86664 - Epstein-Barr Virus Antibody Panel REF,86664,0300,,42.3,31.725,31.725
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],155.5,116.63,116.63,5.07,5.07,94.54,,,,,,00517-9702-25 - droperidol 2.5 mg/mL Sol,J1790,0250,00517-9702-25,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83655,Lab analysis to measure the lead level in blood specimen [HCPCS 83655],123.5,92.63,92.63,12.31,12.31,122.26,,,,,,67457-0839-02 - nitroprusside 25 mg/mL IV Sol [REEV],,0250,67457-0839-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,7.01,5,105.9,,,,,,68084-0326-01 - glimepiride 2 mg Tab [REEV],,0250,68084-0326-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],115.9,86.93,86.93,5.63,5.63,72.8,,,,,,00548-5608-00 - enoxaparin 300 mg/3 mL Sol,J1650,0250,00548-5608-00,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],282.3,211.73,211.73,32.98,32.98,268.8,,,,,,00781-9105-72 - OLANZapine 10 mg Pow [REEV],,0250,00781-9105-72,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],201.9,151.43,151.43,41.96,41.96,133.85,,,,,,64679-0759-02 - furosemide 10 mg/mL 4 mL Inj Sol [REEV],J1940,0250,64679-0759-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84030,"Lab analysis to measure the phenylalanine, PKU (amino acid) level in blood specimen [HCPCS 84030]",102.6,76.95,76.95,4.62,4.62,77.09,,,,,,70860-0300-05 - metoprolol 1 mg/mL Inj Sol [REEV],J3490,0250,70860-0300-05,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],144.5,108.38,108.38,21.2,18.12,87.86,,,,,,57896-0981-01 - aspirin 81 mg Oral EC Tab [REEV],,0250,57896-0981-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],185.3,138.98,138.98,19.7,19.44,112.66,,,,,,63323-0723-03 - remifentanil 1 mg Pow [REEV],,0250,63323-0723-03,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],315.4,236.55,236.55,252.32,18.45,315.4,,,,,,00186-0917-06 - budesonide 90 mcg/inh Pow [REEV],,0250,00186-0917-06,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],58.5,43.88,43.88,3.73,3.73,46.16,,,,,,60267-0705-50 - sodium thiosulfate 25% Sol [REEV],,0250,60267-0705-50,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84402,Lab analysis to measure free testosterone (hormone) level in serum specimen [HCPCS 84402],148.9,111.68,111.68,148.9,25.55,148.9,,,,,,00517-0955-01 - OLANZapine 10 mg Pow [REEV],,0250,00517-0955-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],240.4,180.3,180.3,240.4,25.9,240.4,,,,,,REEV MG Diagnostic Tomo Combo Charge,G0279,0401,,148.5,111.375,111.375
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],61.8,46.35,46.35,0,11.39,37.57,,,,,,45802-0088-01 - albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [REEV],,0250,45802-0088-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],130.1,97.58,97.58,9.17,7.58,134.6,,,,,,00031-2235-19 - brompheniramine-phenylephrine 1 mg-2.5 mg/5 mL oral Liq 118 mL [REEV],,0250,00031-2235-19,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],135.7,101.78,101.78,17.07,14.11,134.34,,,,,,69339-0136-32 - diazepam 5 mg/mL Inj Sol [REEV],J3360,0250,69339-0136-32,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",65.1,48.83,48.83,5.26,4.35,39.58,,,,,,00904-6455-61 - docusate sodium 100 mg Cap [REEV],,0250,00904-6455-61,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",65.1,48.83,48.83,5.38,5.38,38.07,,,,,,63739-0964-25 - heparin 10000 units/mL Sol,J1644,0250,63739-0964-25,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",155.5,116.63,116.63,14.41,14.41,153.94,,,,,,00173-0682-20 - albuterol 90 mcg/inh Aer,,0250,00173-0682-20,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",233.8,175.35,175.35,0,17.22,200.91,,,,,,63323-0221-48 - vancomycin 500 mg Pow,J3370,0250,63323-0221-48,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,12.67,9.87,141.2,,,,,,60432-0606-16 - codeine-promethazine 10 mg-6.25 mg/5 mL Syr,,0250,60432-0606-16,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],53,39.75,39.75,4.02,4.02,32.1,,,,,,"Entamoeba Histolytica Antigen, EIA REF",87337,0300,,63.1,47.325,47.325
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],53,39.75,39.75,4.6,4.54,50.4,,,,,,J2405 Injection Zofran 4mg/mL Inj Sol,J2405,0521,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],195.2,146.4,146.4,17.48,17.05,191.3,,,,,,Zofran ODT 4mg Tab Medication Charge,S0119,0521,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",141.2,105.9,105.9,15.29,12.64,85.85,,,,,,67457-0420-10 - dexamethasone 10 mg/mL Sol,J1100,0250,67457-0420-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],61.8,46.35,46.35,10.11,7.65,55.26,,,,,,66689-0037-50 - 66689-0037-01,,0250,66689-0037-50,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],44.1,33.08,33.08,2.41,2.41,10,,,,,,63323-0599-30 - deferoxamine 2 g Inj [REEV],J0895,0250,63323-0599-30,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],12.2,9.15,9.15,2.41,2.41,10,,,,,,60687-0293-01 - nortriptyline 25 mg Cap [REEV],,0250,60687-0293-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",88.2,66.15,66.15,7.9,6,88.2,,,,,,Chromatin (Nucleosomal) Antibody REF,86235,0300,,155.5,116.625,116.625
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",37.5,28.13,28.13,6.57,5.43,37.5,,,,,,87701-4317-39 - senna 8.6 mg Tab,,0250,87701-4317-39,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],202.9,152.18,152.18,8.55,8.55,182.7,,,,,,36961-0085-88 - multivitamin with minerals Multiple Vitamins with Mi Syrup,,0250,36961-0085-88,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],127.9,95.93,95.93,4.36,3.6,69.6,,,,,,WRIST(LEFT)KUHL WRAP BLACK,,,,40.52,30.39,30.39
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85651,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (non-automated) [HCPCS 85651],42,31.5,31.5,3.59,3.56,42,,,,,,68682-0994-98 - dilTIAZem 180 mg/24 hours Cap [REEV],,0250,68682-0994-98,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],68.3,51.23,51.23,2.75,2.7,54.33,,,,,,SN FREE TEXT ITEM,,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],127.9,95.93,95.93,6.11,6.03,69.6,,,,,,Heat Moisture Exchanger (HME),,,,6.8,5.1,5.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],263.6,197.7,197.7,210.88,12.29,258.33,,,,,,"ANA Screen, IFA, with Reflex to Titer and Pattern/ Lupus Panel 1 REF",86038,0301,,155.5,116.625,116.625
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86039,Lab analysis to screen for autoimmune disorders by titer [HCPCS 86039],91.6,68.7,68.7,73.28,18.5,73.28,,,,,,00338-0085-03 - LVP solution Dextrose 5% with 0.45% NaCl Sol,,0250,00338-0085-03,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],76.2,57.15,57.15,76.2,5.26,76.2,,,,,,25021-0179-16 - DAPTOmycin 350 mg Pow,J0878,0250,25021-0179-16,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],168.8,126.6,126.6,112.96,12.2,112.96,,,,,,U1 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86225,Lab analysis to identify antibodies to native or double stranded DNA [HCPCS 86225],141.2,105.9,105.9,112.96,62.13,112.96,,,,,,U2 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],272.4,204.3,204.3,199.4,18.22,199.4,,,,,,U3 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],722.4,541.8,541.8,187.04,12.25,187.04,,,,,,U4 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86308,Lab analysis to screen for mononucleosis (mono) [HCPCS 86308],53,39.75,39.75,5.26,5.26,30.95,,,,,,U5 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86336,Lab analysis to measure the amount of reproductive organ horomone (inhibin A) [HCPCS 86336],283.4,212.55,212.55,13.1,13.1,25.85,,,,,,U6 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86337,Lab analysis to measure the amount of insulin antibodies [HCPCS 86337],311,233.25,233.25,17.98,17.98,17.98,,,,,,U7 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],186.4,139.8,139.8,97.04,14.79,121.3,,,,,,U8 CCP FSI,P9019,0383,,330.8,248.1,248.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],186.4,139.8,139.8,149.12,5.76,186.4,,,,,,60505-3251-06 - lamiVUDine 150 mg Tab,,0250,60505-3251-06,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],66.2,49.65,49.65,4.34,4.34,61.8,,,,,,00409-6695-01 - etomidate 2 mg/mL Sol,,0250,00409-6695-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],121.3,90.98,90.98,13.94,11.52,121.3,,,,,,60432-0606-16 - codeine-promethazine 10 mg-6.25 mg/5 mL Syr [REEV],,0250,60432-0606-16,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86765,Lab analysis to identify antibodies to Rubeola (measles virus) [HCPCS 86765],169.8,127.35,127.35,10.82,10.82,53.63,,,,,,71288-0402-31 - heparin 1000 units/mL Inj Sol (PHS) [REEV],J1644,0250,71288-0402-31,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],93.8,70.35,70.35,42.13,16.62,74.01,,,,,,"Mycobacterium, Culture, Blood 1 REF",87116,0300,,111.4,83.55,83.55
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86787,Lab analysis to identify antibodies to varicella-zoster virus (chicken pox) [HCPCS 86787],148.9,111.68,111.68,13.09,10.82,90.53,,,,,,"Mycobacterium, Culture, Blood 2 REF",87116,0300,,111.4,83.55,83.55
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],222.7,167.03,167.03,178.16,11.99,222.7,,,,,,"92960 Cardioversion, elective, electrical conversion of arrhythmia, external",92960,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],465.3,348.98,348.98,92.02,6.74,92.02,,,,,,70594-0053-01 - DAPTOmycin 350 mg Pow,J0878,0250,70594-0053-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86870,Lab blood analysis to identify antibodies to red blood cells [HCPCS 86870],201.9,151.43,151.43,182.51,9.61,182.51,,,,,,64788 EXCISION OF NEUROFIBROMA,,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86880,"Lab blood analysis to identify the coating of red blood cells by antibody (Coombs test) (direct, each serum) [HCPCS 86880]",160,120,120,5.48,5.48,31.42,,,,,,Itraconazole REF,80299,0300,,112.6,84.45,84.45
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86886,Lab blood analysis to measure the strength of antibody to red blood cell [HCPCS 86886],155.5,116.63,116.63,5.26,5.26,8.59,,,,,,00591-3128-79 - progesterone 50 mg/mL Sol,J2675,0250,00591-3128-79,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],774,580.5,580.5,3.04,2.99,62.24,,,,,,00049-0013-83 - ampicillin-sulbactam 1 g-0.5 g Inj [REEV],J0295,0250,00049-0013-83,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],116.9,87.68,87.68,3.04,2.99,48.11,,,,,,00386-0001-11 - ethyl chloride Top 100% Spry (PHS) [REEV],,0250,00386-0001-11,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86905,Lab blood analysis to identify antigens of red blood cell antibodies (other than ABO or Rh(D)) [HCPCS 86905],446.6,334.95,334.95,3.9,3.9,3.9,,,,,,61570-0131-25 - silver sulfADIAZINE Top 1% Crm [REEV],,0250,61570-0131-25,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,86920,Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920],123.5,92.63,92.63,56.45,11.93,144.95,,,,,,17478-0937-10 - dilTIAZem 5 mg/mL Sol,J3490,0250,17478-0937-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],141.2,105.9,105.9,10.49,9.2,112.32,,,,,,63323-0751-01 - phenylephrine 10 mg/mL Inj Sol [REEV],J2370,0250,63323-0751-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],54.4,40.8,40.8,9.6,9.6,22.79,,,,,,50268-0131-15 - bumetanide 1 mg Tab [REEV],,0250,50268-0131-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87046,Lab analysis of stool culture to identify bacteria and additional pathogens [HCPCS 87046],54.4,40.8,40.8,7.93,7.93,15.66,,,,,,00168-0099-15 - ketoconazole Top 2% Crm [REEV],,0250,00168-0099-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",99.3,74.48,74.48,8.76,7.24,496.86,,,,,,60687-0437-01 - amiodarone 200 mg Tab [REEV],,0250,60687-0437-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],147.8,110.85,110.85,9.62,9.38,86.39,,,,,,68084-0592-01 - isosorbide mononitrate ER 60 mg Tab [REEV],,0250,68084-0592-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],171,128.25,128.25,8.22,6.79,100.4,,,,,,68084-0271-01 - risperiDONE 0.5 mg Tab [REEV],,0250,68084-0271-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],290.1,217.58,217.58,6.74,5.57,65.1,,,,,,68084-0111-01 - glipiZIDE 5 mg ER Tab [REEV],,0250,68084-0111-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],233.8,175.35,175.35,8.2,2.84,108.1,,,,,,61314-0396-01 - cyclopentolate Ophth 1% Sol [REEV],,0250,61314-0396-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],24.8,18.6,18.6,8.23,6.8,52.43,,,,,,60687-0435-21 - clarithromycin 500 mg Tab [REEV],,0250,60687-0435-21,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87106,Lab analysis of fungal culture to identify yeast [HCPCS 87106],152.2,114.15,114.15,8.67,8.67,29.64,,,,,,42192-0338-01 - hyoscyamine 0.125 mg Dis Tab [REEV],,0250,42192-0338-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],56.8,42.6,42.6,9.05,8.9,23.8,,,,,,16729-0169-01 - escitalopram 10 mg Tab [REEV],,0250,16729-0169-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",172,129,129,8.8,7.27,172,,,,,,00173-0882-14 - fluticasone-vilanterol 200 mcg-25 mcg/inh Pow Inh [REEV],,0250,00173-0882-14,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],160,120,120,5.74,4.29,39.3,,,,,,00088-2102-24 - rifapentine 150 mg Tab [REEV],,0250,00088-2102-24,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],56.8,42.6,42.6,18.27,12.41,29.8,,,,,,43598-0436-11 - nitroglycerin 0.4 mg sublingual Tab [REEV],,0250,43598-0436-11,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87328,Lab analysis by immunoassay (ELISA) to identify cryptosporidium (parasite) [HCPCS 87328],136.8,102.6,102.6,11.61,11.61,22.91,,,,,,00641-6150-10 - neostigmine 0.5 mg/mL Sol,J2710,0250,00641-6150-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87340,Lab analysis by immunoassay (ELISA) to identify Hepatitis B surface antigen [HCPCS 87340],105.9,79.43,79.43,10.5,10.5,44.35,,,,,,00121-1781-00 - acetaminophen 160 mg/5 mL Oral Susp UD [REEV],,0250,00121-1781-00,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87400,Lab analysis by immunoassay (ELISA) to identify Influenza virus (A or B) [HCPCS 87400],155.5,116.63,116.63,14.36,8.17,155.5,,,,,,"TUBE, LEVIN SZ 16 (SUB)",,,,5,3.75,3.75
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87420,Lab analysis by immunoassay (ELISA) to identify respiratory syncytial virus (RSV) [HCPCS 87420],155.5,116.63,116.63,11.68,11.68,116.85,,,,,,"Culture, Fungus, Skin, Hair, Nail with Direct Fluorescent/ KOH REF",87101,0300,,21.4,16.05,16.05
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],110.3,82.73,82.73,45.23,37.79,110.3,,,,,,Thyroid Cancer (Thyroglobulin) Monitor REF,86800,0300,,92.7,69.525,69.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],211.7,158.78,158.78,12.17,11.89,22.79,,,,,,87220-Smear,87220,0300,,11.9,8.925,8.925
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87430,"Lab analysis by immunoassay (ELISA) to identify Strep (Streptococcus, group A) [HCPCS 87430]",78.4,58.8,58.8,17.09,14.12,74.6,,,,,,FILTER GIBECK HUMID-FLO HME,,,,15.12,11.34,11.34
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",342.7,257.03,257.03,12.17,11.91,22.84,,,,,,62584-0994-01 - warfarin 5 mg Tab,,0250,62584-0994-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],155.5,116.63,116.63,35.67,29.48,155.5,,,,,,"Testosterone, Free, Bioavailable and Total, Female/Male REF",82040,0300,,53,39.75,39.75
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],282.3,211.73,211.73,31.31,31.31,118.27,,,,,,COVID-19 Rapid PCR FSI,87635,0300,,165.4,124.05,124.05
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],155.5,116.63,116.63,35.67,29.48,155.5,,,,,,63323-0983-53 - piperacillin-tazobactam 3 g-0.375 g Pow,J2543,0250,63323-0983-53,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],35.3,26.48,26.48,35.67,4.29,35.67,,,,,,"49281-0250-51 - rabies vaccine, human diploid cell 2.5 intl units Pow",,0250,49281-0250-51,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87634,Lab analysis by nucleic acid (DNA or RNA) to identify respiratory syncytial virus by amplified probe technique [HCPCS 87634],157.5,118.13,118.13,71.35,58.97,116.37,,,,,,25021-0165-30 - piperacillin-tazobactam 3 g-0.375 g IV Inj [REEV],J2543,0250,25021-0165-30,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],285.3,213.98,213.98,51.33,45.82,378.9,,,,,,59676-0320-04 - epoetin alfa 20000 units/mL Sol [REEV],J0885,0250,59676-0320-04,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87651,"Lab analysis by nucleic acid (DNA or RNA) to identify Strep (Streptococcus, group A) by amplified probe technique [HCPCS 87651]",105,78.75,78.75,35.67,29.48,105,,,,,,00781-1486-01 - amitriptyline 10 mg Tab [REEV],,0250,00781-1486-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,87800,Lab analysis by nucleic acid (DNA or RNA) to identify multiple organisms by direct probe(s) technique [HCPCS 87800],406.9,305.18,305.18,44.38,40.24,406.9,,,,,,60687-0134-01 - predniSONE 10 mg Tab [REEV],,0250,60687-0134-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,88175,Lab analysis of vaginal or cervical cells (pap test) with automated screening and manual re-screening under physician supervision [HCPCS 88175],33.1,24.83,24.83,27.04,4.29,27.04,,,,,,60687-0453-01 - levothyroxine 25 mcg (0.025 mg) Tab [REEV],,0250,60687-0453-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,88302,Pathology lab analysis of tissue with microscope [HCPCS 88302],33.1,24.83,24.83,0,13.86,24.19,,,,,,51079-0215-20 - celecoxib 200 mg Cap [REEV],,0250,51079-0215-20,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],33.1,24.83,24.83,38.85,20.12,77.89,,,,,,60687-0439-01 - labetalol 100 mg Tab [REEV],,0250,60687-0439-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,89055,Lab analysis to measure the amount of white blood cells in stool specimen [HCPCS 89055],65.1,48.83,48.83,3.59,3.59,27.28,,,,,,57237-0002-01 - hydrochlorothiazide 12.5 mg Cap [REEV],,0250,57237-0002-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],122.5,91.88,91.88,143.78,6.15,4344.87,,,,,,"49281-0120-65 - influenza virus vaccine, inactivated high-dose preservative-free trivalent Sus [REEV",,0250,49281-0120-65,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",713.4,535.05,535.05,166.13,166.13,1092.27,,,,,,"49281-0633-15 - influenza virus vaccine, inactivated quadrivalent Sus [REEV]",,0250,49281-0633-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,94060,Amount and speed of breathed air measurement and graphic recording before and after medication administration [HCPCS 94060],308.7,231.53,231.53,362.32,20,362.32,,,,,,"49281-0720-10 - influenza virus vaccine, inactivated recombinant hemagglutinin quadrivalent Sol [REE",,0250,49281-0720-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,94618,Exercise-induced lung stress test [HCPCS 94618],293.3,219.98,219.98,234.64,234.64,234.64,,,,,,"49281-0190-20 - rabies immune globulin, human 150 units/mL IM Sol [REEV]",,0250,49281-0190-20,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640],83.8,62.85,62.85,98.36,16.49,98.36,,,,,,00781-6139-57 - amoxicillin-clavulanate 600 mg-42.9 mg/5 mL Oral Liq dose [REEV],,0250,00781-6139-57,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,94664,"Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]",528.2,396.15,396.15,64.69,19.15,448.97,,,,,,00093-9364-01 - glyBURIDE 5 mg Tab [REEV],,0250,00093-9364-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],446.6,334.95,334.95,416.66,28.6,1161.38,,,,,,63323-0842-02 - dicyclomine 10 mg/mL Sol,J0500,0250,63323-0842-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],97.1,72.83,72.83,59.59,16.26,2475.42,,,,,,60687-0113-01 - cloNIDine 0.1 mg Tab [REEV],,0250,60687-0113-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",446.6,334.95,334.95,524.17,68.61,524.17,,,,,,68180-0281-01 - ethambutol 400 mg Tab [REEV],,0250,68180-0281-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",97.1,72.83,72.83,90.61,20.72,3197.1,,,,,,60687-0425-01 - NIFEdipine 10 mg Cap [REEV],,0250,60687-0425-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",92.7,69.53,69.53,108.8,34.19,143.78,,,,,,Ethosuximide/ Zarontin REF,80168,0300,,45.1,33.825,33.825
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96368,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (concurrent with another infusion) [HCPCS 96368]",92.7,69.53,69.53,108.8,38.81,108.8,,,,,,"Trichomonas RNA, Qualitative, Males REF",87661,0300,,200.7,150.525,150.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",164.8,123.6,123.6,92.02,4.51,1156.79,,,,,,72611-0725-25 - ketorolac 60 mg/2 mL Sol,J1885,0250,72611-0725-25,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",316.5,237.38,237.38,234.27,29.4,2785.69,,,,,,69097-0846-07 - cyclobenzaprine 10 mg Tab [REEV],,0250,69097-0846-07,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",39.7,29.78,29.78,44.01,12.56,48.28,,,,,,60505-6130-05 - ondansetron 2 mg/mL Inj Sol [REEV],J2405,0250,60505-6130-05,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",39.7,29.78,29.78,44.01,10.24,44.01,,,,,,62756-0512-44 - azithromycin 500 mg IV Inj [REEV],J0456,0250,62756-0512-44,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96900,Ultraviolet light application to skin [HCPCS 96900],92.2,69.15,69.15,0,23.1,23.1,,,,,,50268-0639-15 - pantoprazole 40 mg Oral EC Tab [REEV],,0250,50268-0639-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,97010,Hot or cold packs application to 1 or more areas [HCPCS 97010],48.6,36.45,36.45,0,13.42,41.31,,,,,,00185-0801-30 - rifampin 150 mg Cap [REEV],,0250,00185-0801-30,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",112.5,84.38,84.38,82.25,40.84,136.8,,,,,,61958-2901-01 - remdesivir 100 mg Pow,,0250,61958-2901-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],83.8,62.85,62.85,98.36,23.51,98.36,,,,,,50268-0402-15 - acetaminophen-HYDROcodone 325 mg-10 mg Tab [REEV],,0250,50268-0402-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],365,273.75,273.75,428.4,140.59,428.4,,,,,,69618-0044-01 - docusate sodium 100 mg Cap [REEV],,0250,69618-0044-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],33.1,24.83,24.83,20.77,10.32,28.14,,,,,,"59870 Uterine evac & curettage, hydatiform mole",59870,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,56.98,35.11,337.46,,,,,,"17003 Destruction lesion, premalignant, second through fourteenth",17003,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],254.8,191.1,191.1,254.8,70.45,319.43,,,,,,"56501 Destruction of lesions, vulva",56501,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],131.3,98.48,98.48,100.17,2.2,117.5,,,,,,"17110 Destruction, benign lesions other than skin tags, up to 14 lesions",17110,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],244.8,183.6,183.6,72.73,39.1,434.06,,,,,,00906 ANES Vulvectomy,00906,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],384.9,288.68,288.68,293.64,61.48,2109.82,,,,,,Cryo Storage/Handling Fee,P9012,0390,,135.2,101.4,101.4
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],570.1,427.58,427.58,669.13,50,3116.59,,,,,,00904-6799-61 - lisinopril 20 mg Tab [REEV],,0250,00904-6799-61,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],936.1,702.08,702.08,1098.7,62.92,1098.7,,,,,,Myelin Oligodendroxyte Glycoprotein (MOG) Antibody w/ Reflex to Titer REF,86255,0300,,722.4,541.8,541.8
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],24.3,18.23,18.23,18.73,5.83,3301.98,,,,,,"Destruction lesion, premalignant, second through fourteenth",17003,0521,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],24.3,18.23,18.23,18.73,7.4,19.63,,,,,,"17110 Destruction, benign lesions other than skin tags, up to 14 lesions.",17110,0521,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0131,Acetaminophen injection [HCPCS J0131],11.1,8.33,8.33,13.03,3.22,2266.54,,,,,,55513-0742-10 - etelcalcetide 5 mg/mL Sol [REEV],J0606,0250,55513-0742-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0290,Ampicillin 500 mg inj [HCPCS J0290],12.5,9.38,9.38,10.13,1.19,25,,,,,,00187-0746-33 - glucose 24 g/31 g Gel,,0250,00187-0746-33,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0330,Succinycholine chloride inj [HCPCS J0330],3.95,2.96,2.96,0,1.74,3.04,,,,,,50268-0732-12 - sucralfate 1 g/10 mL Supp,,0250,50268-0732-12,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0595,Butorphanol tartrate 1 mg [HCPCS J0595],25,18.75,18.75,20,3.58,20,,,,,,70436-0019-82 - azithromycin 500 mg IV Inj [REEV],J0456,0250,70436-0019-82,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0690,Cefazolin sodium injection [HCPCS J0690],12.5,9.38,9.38,9.6,5.5,14.67,,,,,,00406-0125-62 - acetaminophen-HYDROcodone 325 mg-10 mg Tab [REEV],,0250,00406-0125-62,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0694,Cefoxitin sodium injection [HCPCS J0694],25,18.75,18.75,0,6.27,15.35,,,,,,"99157 Moderate sedation, other physician, ea add'l 15 minutes, any age",99157,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0696,Ceftriaxone sodium injection [HCPCS J0696],6.25,4.69,4.69,7.34,0.68,2868.2,,,,,,"99155 Moderate sedation, other physician, initial 15 minutes, < 5 yrs",99155,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0702,Betamethasone acet&sod phosp [HCPCS J0702],3.09,2.32,2.32,3.63,3.63,3.74,,,,,,56620 Vulvectomy simple; partial.,56620,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J0780,Prochlorperazine injection [HCPCS J0780],55.5,41.63,41.63,65.14,13.53,65.14,,,,,,"58700 Salpingectomy, complete or partial, unilateral or bilateral.",58700,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J1100,Dexamethasone sodium phos [HCPCS J1100],2.5,1.88,1.88,2.03,0.11,332.88,,,,,,"58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral.",58720,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J1200,Diphenhydramine hcl injectio [HCPCS J1200],25,18.75,18.75,29.34,2.1,2819.66,,,,,,00641-6147-10 - sterile water 10 mL Inj Sol [REEV],,0250,00641-6147-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J1630,Haloperidol injection [HCPCS J1630],25,18.75,18.75,29.34,1.08,29.34,,,,,,"Drug Monitoring, Alcohol Metabolite, W/Confirmation, W/MedMATCH Urine REF",80307,0300,,311,233.25,233.25
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2001,Lidocaine injection [HCPCS J2001],25,18.75,18.75,1.92,0.73,808.23,,,,,,00641-6147-25 - sterile water 10 mL Inj Sol [REEV],,0250,00641-6147-25,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],25,18.75,18.75,29.34,7.08,29.34,,,,,,65862-0859-01 - famotidine 20 mg Tab [REEV],,0250,65862-0859-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2175,Meperidine hydrochl /100 mg [HCPCS J2175],25,18.75,18.75,19.2,7.8,30.4,,,,,,70860-0100-10 - azithromycin 500 mg IV Inj [REEV],J0456,0250,70860-0100-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],12.5,9.38,9.38,0,5.5,14.67,,,,,,00069-3150-83 - azithromycin 500 mg IV Inj [REEV],J0456,0250,00069-3150-83,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],25,18.75,18.75,20.27,3.15,30.39,,,,,,43598-0839-36 - methocarbamol 100 mg/mL Inj Sol [REEV],,0250,43598-0839-36,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],12.5,9.38,9.38,14.67,0.95,3583.7,,,,,,"51860 Cystorrhaphy, suture of bladder wound, injury or rupture",51860,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,13.45,1.72,16.28,,,,,,"Estradiol, Free REF",82670,0300,,480.7,360.525,360.525
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],25,18.75,18.75,29.34,2.81,811.33,,,,,,00904-5823-60 - cholecalciferol 400 intl units Tab [REEV],,0250,00904-5823-60,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2675,Inj progesterone per 50 mg [HCPCS J2675],1.25,0.94,0.94,29.34,1.41,29.34,,,,,,59746-0362-90 - valsartan 160 mg Tab,,0250,59746-0362-90,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",1.25,0.94,0.94,0.96,0.55,29.34,,,,,,64980-0134-01 - dipyridamole 50 mg Tab [REEV],,0250,64980-0134-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2920,Methylprednisolone injection [HCPCS J2920],25,18.75,18.75,12,5.3,21.25,,,,,,Fibrosis Score REF,,0300,,0,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],29.07,21.8,21.8,13.96,5.49,347.63,,,,,,68094-0043-62 - sucralfate 1 g/10 mL Sus,,0250,68094-0043-62,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],8.33,6.25,6.25,0,5.12,5.12,,,,,,96372 Subsequent IM Injection,96372,0260,,164.8,123.6,123.6
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J3030,Sumatriptan succinate / 6 mg [HCPCS J3030],212.5,159.38,159.38,179.73,87.42,179.73,,,,,,"11403 Excision, benign lesion, 2.1 to 3.0 cm",11403,0521,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],6.38,4.79,4.79,3.06,1.29,348.28,,,,,,00002-7910-01 - bamlanivimab 700 mg Soln,,0250,00002-7910-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,14.67,5.5,19.14,,,,,,.Flex Hexagonal Phase Confirmation REF.,85598,0300,,132.3,99.225,99.225
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],20,15,15,15.36,1.66,23.47,,,,,,55150-0306-10 - progesterone 50 mg/mL IM Sol [REEV],J2675,0250,55150-0306-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,23.48,1.76,23.48,,,,,,68382-0310-30 - nitroglycerin 0.4 mg/hr Fil,,0250,68382-0310-30,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,28,0.02,4433.9,,,,,,00225-0800-47 - phenylephrine nasal 0.25% Spr,,0250,00225-0800-47,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J7510,Prednisolone oral per 5 mg [HCPCS J7510],10.36,7.77,7.77,4.97,2.49,8.81,,,,,,00225-0810-47 - phenylephrine nasal 1% Spr,,0250,00225-0810-47,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J7613,Albuterol non-comp unit [HCPCS J7613],5,3.75,3.75,2.4,2.4,4.25,,,,,,00641-6194-10 - propofol 10 mg/mL 20 mL IV Emul [REEV],J2704,0250,00641-6194-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,S0020,"Injection, bupivicaine hydro [HCPCS S0020]",2.5,1.88,1.88,2.93,2.93,11.2,,,,,,63323-0269-29 - propofol 10 mg/mL 20 mL IV Emul [REEV],J2704,0250,63323-0269-29,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Institutional,Outpatient,S0171,Bumetanide 0.5 mg [HCPCS S0171],12.5,9.38,9.38,9.6,5.75,9.6,,,,,,63323-0516-10 - dexamethasone 10 mg/mL Inj Sol MDV [REEV],J1100,0250,63323-0516-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],3533.3,2649.98,2649.98,16.21,8.8,16.21,,,,,,70069-0025-10 - dexamethasone 10 mg/mL Inj Sol MDV [REEV],J1100,0250,70069-0025-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],238.4,178.8,178.8,123.34,104.9,146.74,,,,,,00075-0624-30 - enoxaparin 30 mg/0.3 mL Sol,J1650,0250,00075-0624-30,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1281,960.75,960.75,272.21,272.21,272.21,,,,,,63323-0269-69 - propofol 10 mg/mL 100 mL IV Emul [REEV],J2704,0250,63323-0269-69,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,80050,Lab analysis also known as general health panel [HCPCS 80050],447.4,335.55,335.55,362.71,362.71,362.71,,,,,,76204-0300-03 - sodium chloride 0.9% Sol,,0250,76204-0300-03,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],283.5,212.63,212.63,17.42,9.98,223.68,,,,,,24201-0585-10 - dicyclomine 10 mg/mL Sol,J0500,0250,24201-0585-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],86,64.5,64.5,11.4,11.4,11.4,,,,,,REACHER 26' WEIGHT 6oz,,,,12.63,9.4725,9.4725
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,80329,Lab analysis to measure analgesics levels (1 or 2) in serum/plasma or urine specimen [HCPCS 80329],131.3,98.48,98.48,11.65,11.65,11.65,,,,,,SHOE HORN PLASTIC HOMECRAFT,,,,11.34,8.505,8.505
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],72.5,54.38,54.38,3.22,3.22,57.2,,,,,,SOCK AND STOCKING AID W/ FOAM HANDLES,,,,11.12,8.34,8.34
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,81025,Lab analysis of urine specimen by dipstick to detect the hormone found in women in early pregnancy [HCPCS 81025],25.5,19.13,19.13,8.75,5.3,61.31,,,,,,BENDABLE CONTOUR SPONGE,,,,5.01,3.7575,3.7575
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],94.5,70.88,70.88,11.74,11.74,11.74,,,,,,"RIGID LEG LIFTER(MOST ADULT 5-41"")",,,,7.06,5.295,5.295
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],74.6,55.95,55.95,6.96,6.96,6.96,,,,,,FOOT FUNNEL,,,,18.18,13.635,13.635
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",184.8,138.6,138.6,11.76,11.76,11.76,,,,,,00904-0523-60 - ascorbic acid 500 mg Tab [REEV],,0250,00904-0523-60,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],105.9,79.43,79.43,7.01,4.7,7.01,,,,,,82947,82947,0300,,50.8,38.1,38.1
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],55.7,41.78,41.78,4.93,4.93,4.93,,,,,,84450,84450,0300,,65.1,48.825,48.825
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],129.2,96.9,96.9,17.07,17.07,101.94,,,,,,84460,84460,0300,,65.1,48.825,48.825
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],141.2,105.9,105.9,12.67,6.71,12.67,,,,,,85049,85049,0300,,32.1,24.075,24.075
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",84,63,63,7.9,5.31,66.28,,,,,,68001-0433-90 - nicotine 14 mg/24 hr Film-ER,,0250,68001-0433-90,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],182.7,137.03,137.03,10.35,10.35,80.39,,,,,,68084-0070-01 - ciprofloxacin 500 mg Tab,,0250,68084-0070-01,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],69.6,52.2,52.2,5.76,2.69,69.6,,,,,,64380-0766-21 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [REEV],,0250,64380-0766-21,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],58.8,44.1,44.1,5.74,5.74,5.74,,,,,,63323-0269-94 - propofol 10 mg/mL 20 mL IV Emul [REEV],J2704,0250,63323-0269-94,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,86703,Lab analysis to identify antibodies to HIV-1 and HIV-2 virus [HCPCS 86703],115.5,86.63,86.63,18.43,18.43,18.43,,,,,,72611-0757-10 - rocuronium 10 mg/mL Injection,,0250,72611-0757-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],74.6,55.95,55.95,57.29,57.29,57.29,,,,,,"Chlamydia/ Neisseria Gonorrhoeae RNA, Throat REF",87491,0300,,148.1,111.075,111.075
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],58.8,44.1,44.1,4.02,4.02,4.02,,,,,,"87591-NEISSERIA GONORRHOEAE RNA, THROAT",87591,0300,,148.1,111.075,111.075
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],46.2,34.65,34.65,4.02,4.02,4.02,,,,,,20555-0033-00 - cholecalciferol 1000 intl units Tab,,0250,20555-0033-00,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],134.4,100.8,100.8,10.49,10.49,10.49,,,,,,65162-0102-10 - gabapentin 300 mg Cap,,0250,65162-0102-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],95.6,71.7,71.7,8.22,8.22,8.22,,,,,,16729-0216-15 - sertraline 50 mg Tab,,0250,16729-0216-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],102.9,77.18,77.18,8.2,5.29,8.2,,,,,,Early Sjogren's Syndrome Profile REF,83520,0300,,408.1,306.075,306.075
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],23.6,17.7,17.7,8.23,8.23,8.23,,,,,,TRAY CATHETER(NON LATEX) 14FR,,,,22.34,16.755,16.755
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],105,78.75,78.75,60.46,60.46,60.46,,,,,,68084-0309-21 - valACYclovir 1 g Tab,,0250,68084-0309-21,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87536,Lab analysis by nucleic acid (DNA or RNA) to meaure the amount of HIV-1 virus [HCPCS 87536],465.2,348.9,348.9,114.37,114.37,114.37,,,,,,59746-0383-06 - terazosin 1 mg Cap,,0250,59746-0383-06,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87538,Lab analysis by nucleic acid (DNA or RNA) to identify HIV-2 virus by amplified probe technique [HCPCS 87538],268.06,201.05,201.05,47.17,47.17,47.17,,,,,,00527-6004-80 - lidocaine topical 4% Sol [REEV],,0250,00527-6004-80,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],157.5,118.13,118.13,51.33,51.33,124.27,,,,,,50268-0400-15 - acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [REEV],,0250,50268-0400-15,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],116.6,87.45,87.45,94.53,7.4,100.98,,,,,,00904-6708-61 - azithromycin 250 mg Tab,,0250,00904-6708-61,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],425.3,318.98,318.98,344.79,335.56,344.79,,,,,,00904-6378-61 - ciprofloxacin 500 mg Tab [REEV],,0250,00904-6378-61,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",425.3,318.98,318.98,344.79,187.13,446.6,,,,,,63323-0325-14 - acyclovir 50 mg/mL IV Sol [REEV],J0133,0250,63323-0325-14,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",77.7,58.28,58.28,62.99,62.99,62.99,,,,,,SUTURE-0PDS 991G,,,,14.94,11.205,11.205
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",301.4,226.05,226.05,231.48,132.62,231.48,,,,,,55150-0221-10 - etomidate 2 mg/mL IV Sol [REEV],,0250,55150-0221-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",79.4,59.55,59.55,30.65,30.65,30.65,,,,,,70121-1049-02 - triamcinolone acetonide 40 mg/mL 1 mL Inj Susp [REEV],J3301,0250,70121-1049-02,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",35.7,26.78,26.78,27.42,15.71,27.42,,,,,,00955-1003-10 - enoxaparin 30 mg/0.3 mL UD inj [REEV],J1650,0250,00955-1003-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],447.7,335.78,335.78,669.13,428.35,1744.38,,,,,,00955-1004-10 - enoxaparin 40 mg/0.4 mL Sol UD [REEV],J1650,0250,00955-1004-10,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],657.1,492.83,492.83,722.74,158.84,722.74,,,,,,Cardiolipin IgG Ab SF,,,,,,
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],23.1,17.33,17.33,17.74,10.16,17.74,,,,,,"JAK2, Exon 12 Mutation Analysis REF",81403,0300,,486.2,364.65,364.65
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,G0379,Direct refer hospital observ [HCPCS G0379],23.1,17.33,17.33,23.1,23.1,23.1,,,,,,"Poliovirus (Types1,3) Antibodies, Neutralization REF",86382,0301,,147,110.25,110.25
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,J0290,Ampicillin 500 mg inj [HCPCS J0290],12.5,9.38,9.38,8.07,8.07,8.07,,,,,,86382-ADD ON,86382,0300,,147,110.25,110.25
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],8.33,6.25,6.25,6.76,6.76,6.76,,,,,,"Meningitidis, IgG, Vaccine Response REF",86317,0300,,48.5,36.375,36.375
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],12.5,9.38,9.38,10.14,10.14,10.14,,,,,,86317-SEROGROUP C,86317,0300,,48.5,36.375,36.375
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],20,15,15,0,20,20,,,,,,86317-SEROGROUP Y,86317,0300,,48.5,36.375,36.375
FIRSTCARE - Commercial-Mut Defined,Hospital,Professional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],35,26.25,26.25,0,1710.43,1710.43,,,,,,86317-SEROGROUP W-135,86317,0300,,48.5,36.375,36.375
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,948,Anesthesia provided during suture closure of cervix [HCPCS 00948],1058.4,793.8,793.8,38.26,38.26,170.05,,,,,,72611-0740-10 - metoprolol 1 mg/mL Sol,J3490,0250,72611-0740-10,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],1587.6,1190.7,1190.7,43.04,43.04,43.04,,,,,,71288-0403-02 - heparin 5000 units/mL Sol,J1644,0250,71288-0403-02,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,1968,Anesthesia provided during cesarean delivery following labor [HCPCS 01968],176.4,132.3,132.3,29.83,29.83,29.83,,,,,,42023-0115-10 - ketamine 100 mg/mL Inj Sol [REEV],,0250,42023-0115-10,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],361.7,271.28,271.28,79.43,73.08,424.53,,,,,,"00264-4460-30 - Fat Emul, 20% IV 250 mL [REEV]",,0250,00264-4460-30,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],339.6,254.7,254.7,155.23,81.5,323.4,,,,,,63323-0482-17 - epinephrine-lidocaine 1:100000-1% Sol,,0250,63323-0482-17,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1721,1290.75,1290.75,0,1305.45,1305.45,,,,,,"Chromosome Analysis, Blood REF",88230,0300,,305.8,229.35,229.35
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2038.1,1528.58,1528.58,693.26,693.26,693.26,,,,,,"88262 -Chromosome Analysis, Blood REF",88262,0300,,681.4,511.05,511.05
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],124.7,93.53,93.53,56.98,35.11,337.46,,,,,,Immunoglobulin G Subclass 4 REF,82787,0300,,102.6,76.95,76.95
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,0,69.82,69.82,,,,,,Calcitonin REF.,82308,0300,,70.4,52.8,52.8
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],49.7,37.28,37.28,0,69.32,94.91,,,,,,Vitamin A REF,84590,0300,,30.5,22.875,22.875
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],103.1,77.33,77.33,0,35.33,37.53,,,,,,Filaria Antibody (IgG4) REF,86682,0300,,92.9,69.675,69.675
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",314,235.5,235.5,59.3,55.67,329.7,,,,,,64380-0808-06 - ibuprofen 600 mg Tab [REEV],,0250,64380-0808-06,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],194.3,145.73,145.73,78.75,73.93,98.64,,,,,,08290-3065-53 - sodium chloride 0.9% Inj Sol 10 mL [REEV],,0250,08290-3065-53,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99465,Newborn resuscitation at delivery [HCPCS 99465],479.7,359.78,359.78,151.06,138.98,151.06,,,,,,08881-5701-21 - sodium chloride 0.9% Inj Sol 10 mL [REEV],,0250,08881-5701-21,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,400,"Anesthesia provided during procedure on skin of arms, legs, or trunk [HCPCS 00400]",139,104.25,104.25,39.16,3.97,330,,,,,,60505-7084-02 - fentaNYL 100 mcg/hr Transderm ER Film [REEV],,0250,60505-7084-02,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],139,104.25,104.25,89.5,1.93,464.4,,,,,,70069-0362-10 - sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol 10 mL [REEV],,0250,70069-0362-10,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,832,Anesthesia provided during middle or incisional abdominal hernia repair [HCPCS 00832],139,104.25,104.25,85.14,4.64,85.14,,,,,,68180-0675-11 - oseltamivir 30 mg Cap [REEV],,0250,68180-0675-11,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,840,Anesthesia provided during procedure in lower abdominal cavity with use of an endoscope [HCPCS 00840],139,104.25,104.25,35.43,4.8,352,,,,,,00378-6470-97 - scopolamine 1.5 mg Transderm ER Film [REEV],,0250,00378-6470-97,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,851,Anesthesia provided during tying or incision of fallopian tubes using an endoscope [HCPCS 00851],139,104.25,104.25,42.51,5.72,268.49,,,,,,00904-6401-61 - tamsulosin 0.4 mg Oral Cap [REEV],,0250,00904-6401-61,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,1960,Anesthesia provided during vaginal delivery [HCPCS 01960],139,104.25,104.25,8.73,1.24,296.76,,,,,,70069-0005-10 - cyanocobalamin 1000 mcg/mL Inj Sol [REEV],J3420,0250,70069-0005-10,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,1961,Anesthesia provided during cesarean delivery [HCPCS 01961],139,104.25,104.25,41.95,5.74,329.73,,,,,,00781-3156-95 - acetaminophen 10 mg/mL [REEV],J0131,0250,00781-3156-95,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,1967,Anesthesia provided during labor during planned vaginal delivery [HCPCS 01967],139,104.25,104.25,43.04,3.36,245.34,,,,,,60687-0457-01 - ibuprofen 600 mg Tab,,0250,60687-0457-01,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,1968,Anesthesia provided during cesarean delivery following labor [HCPCS 01968],139,104.25,104.25,28.77,2.99,188.42,,,,,,MESH(11cm) VENTRALIGHT ECHO SYSTEM,,,,"1,487.85",1115.8875,1115.8875
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,19020,Breast cyst incision and drainage [HCPCS 19020],790.5,592.88,592.88,226.77,226.77,226.77,,,,,,"Organic Acids, Comp. Quanti Urine REF",83918,0300,,62,46.5,46.5
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1596.5,1197.38,1197.38,0,51.74,302.2,,,,,,"82570-Organic Acids, Comp. Quanti Urine REF",82570,0300,,58.8,44.1,44.1
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,49653,Abdominal or navel hernia repair with endoscope (herniated tissue that is trapped) [HCPCS 49653],3339.6,2504.7,2504.7,940.93,940.93,1503.19,,,,,,Bill Only Calcium 24HR MCH,82340,0300,,18.5,13.875,13.875
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,54150,Foreskin removal by clamp or device [HCPCS 54150],766.3,574.73,574.73,79.43,79.43,766.3,,,,,,64253-0111-30 - sodium chloride 0.9% Inj Sol 10 mL [REEV],,0250,64253-0111-30,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,57505,Cervix tissue scraping [HCPCS 57505],383.7,287.78,287.78,33.28,33.28,76.81,,,,,,63323-0106-26 - magnesium sulfate 2 g/50 mL-sterile water [REEV],,0250,63323-0106-26,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,58563,Uterus examination with uterine lining destruction and endoscope [HCPCS 58563],7445.3,5583.98,5583.98,127.52,127.52,393.81,,,,,,70010-0063-01 - metFORMIN 500 mg Tab [REEV],,0250,70010-0063-01,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,58611,Fallopian tubes tying or incision at time of cesarean delivery or other abdominal surgery [HCPCS 58611],423.4,317.55,317.55,0,9.22,121.22,,,,,,"P9046 Infusion, albumin (human) 25%, 20 ml",P9046,0260,,55.1,41.325,41.325
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,58615,Fallopian tubes tying by device through vagina or incision in pubic hairline [HCPCS 58615],1148.8,861.6,861.6,102.11,102.11,388.23,,,,,,"P9047 Infusion, albumin (human) 25%, 50 ml",P9047,0260,,137.7,103.275,103.275
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,58670,Ovaries destrustion with endoscope [HCPCS 58670],2552.4,1914.3,1914.3,276.66,186.15,276.66,,,,,,00143-9251-10 - rocuronium 10 mg/mL IV Sol [REEV],,0250,00143-9251-10,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,58671,Blocking of uterine tubes by device with endoscope [HCPCS 58671],1591,1193.25,1193.25,275.86,275.86,577.59,,,,,,00121-0854-16 - sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [REEV],,0250,00121-0854-16,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,58700,Uterine tubes removal [HCPCS 58700],3084.8,2313.6,2313.6,593.95,593.95,1249.59,,,,,,70069-0271-05 - verapamil 2.5 mg/mL IV Sol [REEV],,0250,70069-0271-05,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,59025,Evaluation of fetal response to its own activity (fetal non-stress test) [HCPCS 59025],71.8,53.85,53.85,22.99,22.99,68.3,,,,,,68180-0722-04 - cefdinir 125 mg/5 mL Pow btl [REEV],,0250,68180-0722-04,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,59409,Delivery of infant through uterus and vagina [HCPCS 59409],1807.1,1355.33,1355.33,583.91,583.91,1462.85,,,,,,42292-0003-20 - digoxin 125 mcg (0.125 mg) Tab [REEV],,0250,42292-0003-20,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,59414,Placenta removal after delivery of infant [HCPCS 59414],583.3,437.48,437.48,67.92,67.92,67.92,,,,,,25021-0400-30 - heparin 1000 units/mL Inj Sol (PHS) [REEV],J1644,0250,25021-0400-30,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,59514,Delivery of infant through incision in abdomen and uterus (cesarean delivery) [HCPCS 59514],2140,1605,1605,673.72,138.2,1470.79,,,,,,63323-0482-57 - epinephrine-lidocaine 1:100000-1% Sol 50mL [REEV],J0171,0250,63323-0482-57,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99140,Anesthetic treatment complicated by emergency condition [HCPCS 99140],139,104.25,104.25,70.32,70.32,70.32,,,,,,KIT HIP KNEE EQUIPMENT,,,,46.67,35.0025,35.0025
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],25.2,18.9,18.9,14.96,8.98,23.86,,,,,,70860-0454-01 - desmopressin 4 mcg/mL Vial,J2597,0250,70860-0454-01,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,13.55,13.55,72.8,,,,,,00641-6207-25 - LORazepam 2 mg/mL Inj Sol [REEV],J2060,0250,00641-6207-25,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],178.6,133.95,133.95,52.38,52.38,170.1,,,,,,"58925 Removal, ovarian cyst(s)",58925,,,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],217.3,162.98,162.98,52.53,52.53,206.9,,,,,,"24076 Excision, tumor, soft tissue upper arm or elbow, subfascial < 5 cm",24076,,,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],296.7,222.53,222.53,81.71,81.71,178.67,,,,,,"24073 Excision, tumor, soft tissue upper arm or elbow, subfascial 5 cm or greater",24073,,,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],371.6,278.7,278.7,122.95,122.95,194.97,,,,,,47781-0428-47 - fentaNYL 100 mcg/hr Transderm ER Film [REEV],,0250,47781-0428-47,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],326.4,244.8,244.8,95.05,95.05,222.03,,,,,,55513-0741-10 - etelcalcetide 5 mg/mL Sol,J0606,0250,55513-0741-10,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99224,Subsequent observation care (typically 15 minutes per day) [HCPCS 99224],108.3,81.23,81.23,22.37,22.37,41.75,,,,,,68682-0006-10 - diltiazem 30 mg Tab [REEV],,0250,68682-0006-10,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],199.2,149.4,149.4,39.55,39.55,134.08,,,,,,10572-0100-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [REEV],,0250,10572-0100-01,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],123.5,92.63,92.63,35.13,31.68,51.15,,,,,,00641-6145-25 - dexamethasone 4 mg/mL 1 mL Inj Sol [REEV],J1100,0250,00641-6145-25,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],171,128.25,128.25,45.48,45.48,91.29,,,,,,63323-0485-27 - lidocaine 1% 20 mL MDV Inj Sol [REEV],J2001,0250,63323-0485-27,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],343,257.25,257.25,114.76,114.76,176.55,,,,,,42023-0201-01 - levothyroxine 100 mcg (0.1 mg) Pow [REEV],,0250,42023-0201-01,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99235,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235],458.7,344.03,344.03,143.04,142.98,177.83,,,,,,00121-1154-40 - lactulose 10 g/15 mL ORAL solution [REEV],,0250,00121-1154-40,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",329.7,247.28,247.28,60.51,59.99,274.04,,,,,,NEEDLE 25G X 1 SAFETY,,,,5,3.75,3.75
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",326.4,244.8,244.8,0,33.41,326.4,,,,,,Diphtheria and Tetanus Antitoxoids REF,86648,0300,,141.2,105.9,105.9
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99460,Initial care for evaluation and management of newborn infant seen in hospital or birthing center (per day) [HCPCS 99460],204.1,153.08,153.08,80.36,77,101.03,,,,,,86774-Diphtheria and Tetanus Antitoxoids REF,86774,0300,,155.5,116.625,116.625
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99462,Subsequent hospital care of newborn infant (per day) [HCPCS 99462],87.2,65.4,65.4,38.82,38.82,44.36,,,,,,Bordetella Pertussis Toxin AB IgG REF,86615,0300,,116.9,87.675,87.675
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99463,Initial care for evaluation and management of newborn infant seen in hospital or birthing center admitted and discharged on same date (per day) [HCPCS 99463],211.7,158.78,158.78,109.55,109.55,109.55,,,,,,49702-0213-26 - zidovudine 10 mg/mL Sol,J3485,0250,49702-0213-26,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99464,Newborn delivery and stabilization with physician attendance [HCPCS 99464],211.7,158.78,158.78,89.75,79.03,89.75,,,,,,65862-0048-24 - zidovudine 50 mg/5 mL Syr,,0250,65862-0048-24,,,
FIRSTCARE - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99465,Newborn resuscitation at delivery [HCPCS 99465],412.4,309.3,309.3,151.06,151.06,151.06,,,,,,00781-3232-95 - pantoprazole 40 mg IV Inj [REEV],,0250,00781-3232-95,,,
FOCUSED POST ACUTE CARE PARTNERS - Commercial-PPO,Clinic,Professional,Outpatient,87880,Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880],46.3,34.73,34.73,44.1,1.28,46.3,,,,,,SUTURE ETHIBOND 0 DS-4 X517H,,,,,,
FOCUSED POST ACUTE CARE PARTNERS - Commercial-PPO,Clinic,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],73.1,54.83,54.83,69.3,13.55,72.8,,,,,,"HIV-2 DNA/RNA, Qualitative, PCR REF",87538,0300,,281.5,211.125,211.125
FOCUSED POST ACUTE CARE PARTNERS - Commercial-PPO,Clinic,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],105.9,79.43,79.43,100.8,62.38,245.75,,,,,,00904-6720-59 - acetaminophen 500 mg Tab [REEV],,0250,00904-6720-59,,,
,,,,,,,,,,,,,,,,,00641-6228-25 - thiamine 100 mg/mL Inj Sol [REEV],J3411,0250,00641-6228-25,,,
,,,,,,,,,,,,,,,,,60505-7082-02 - fentaNYL 50 mcg/hr Transderm ER Film [REEV],,0250,60505-7082-02,,,
,,,,,,,,,,,,,,,,,60505-7081-02 - fentaNYL 25 mcg/hr Transderm ER Film [REEV],,0250,60505-7081-02,,,
,,,,,,,,,,,,,,,,,60505-7083-02 - fentaNYL 75 mcg/hr Transderm ER Film [REEV],,0250,60505-7083-02,,,
,,,,,,,,,,,,,,,,,"49281-0252-51 - rabies vaccine, human diploid cell 2.5 intl units Pow UD [REEV]",,0250,49281-0252-51,,,
,,,,,,,,,,,,,,,,,60687-0580-01 - gabapentin 100 mg Cap [REEV],,0250,60687-0580-01,,,
,,,,,,,,,,,,,,,,,63323-0474-01 - haloperidol 5 mg/mL Inj Sol [REEV],J1630,0250,63323-0474-01,,,
,,,,,,,,,,,,,,,,,00143-9284-10 - pantoprazole 40 mg IV Inj [REEV],,0250,00143-9284-10,,,
,,,,,,,,,,,,,,,,,00781-1487-01 - amitriptyline 25 mg Tab [REEV],,0250,00781-1487-01,,,
,,,,,,,,,,,,,,,,,00054-4146-22 - clotrimazole 10 mg Loz [REEV],,0250,00054-4146-22,,,
,,,,,,,,,,,,,,,,,68084-0851-01 - doxazosin 2 mg Tab [REEV],,0250,68084-0851-01,,,
,,,,,,,,,,,,,,,,,31722-0131-30 - dutasteride 0.5 mg Cap [REEV],,0250,31722-0131-30,,,
,,,,,,,,,,,,,,,,,00093-1177-01 - neomycin 500 mg Tab [REEV],,0250,00093-1177-01,,,
,,,,,,,,,,,,,,,,,24979-0133-01 - terbutaline 5 mg Tab [REEV],,0250,24979-0133-01,,,
,,,,,,,,,,,,,,,,,00378-6992-52 - albuterol 0.042% Inh Sol 3 mL [REEV],J7613,0250,00378-6992-52,,,
,,,,,,,,,,,,,,,,,51079-0810-20 - glipiZIDE 5 mg Tab [REEV],,0250,51079-0810-20,,,
,,,,,,,,,,,,,,,,,KII BALLOON BLUNT TIP SYSTEM,,,,156,117,117
,,,,,,,,,,,,,,,,,72611-0761-10 - vancomycin 500 mg IV Inj [REEV],J3370,0250,72611-0761-10,,,
,,,,,,,,,,,,,,,,,63323-0173-94 - gentamicin 10 mg/mL Inj Sol [REEV],J1580,0250,63323-0173-94,,,
,,,,,,,,,,,,,,,,,72578-0082-01 - acyclovir topical 5% Oin [REEV],,0250,72578-0082-01,,,
,,,,,,,,,,,,,,,,,00574-0521-04 - charcoal 25 g Oral Susp 120 mL [REEV],,0250,00574-0521-04,,,
,,,,,,,,,,,,,,,,,.Reflex Smooth Muscle AB Titer REF,86256,0300,,115.9,86.925,86.925
,,,,,,,,,,,,,,,,,63323-0540-36 - heparin 1000 units/mL Inj Sol (PHS) [REEV],J1644,0250,63323-0540-36,,,
,,,,,,,,,,,,,,,,,42494-0416-25 - PHENobarbital 130 mg/mL Inj Sol [REEV],J2560,0250,42494-0416-25,,,
,,,,,,,,,,,,,,,,,"21552 Excision, tumor, soft tissue of neck or anterior thorax, subcu, 3cm/>",21552,,,,,
,,,,,,,,,,,,,,,,,24385-0325-58 - sodium chloride Nasal 0.65% Spry [REEV],,0250,24385-0325-58,,,
,,,,,,,,,,,,,,,,,ELECTRODE INSULATED SHROUDED BLADE EDGE,,,,30.89,23.1675,23.1675
,,,,,,,,,,,,,,,,,CATHETER URETHRAL REDRUBBER STERILE 16FR,,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,69784-0003-06 - fluconazole 400 mg/200 mL-0.9% Sol,J1450,0250,69784-0003-06,,,
,,,,,,,,,,,,,,,,,00869-0166-38 - magnesium citrate 8.85% Oral Liq 300 mL [REEV],,0250,00869-0166-38,,,
,,,,,,,,,,,,,,,,,SPLINT(PEDI) HARE TRACTION,,,,503.1,377.325,377.325
,,,,,,,,,,,,,,,,,SPLINT(ADULT) HARE TRACTION,,,,503.1,377.325,377.325
,,,,,,,,,,,,,,,,,25021-0115-04 - clindamycin 150 mg/mL IV Sol [REEV],,0250,25021-0115-04,,,
,,,,,,,,,,,,,,,,,51079-0734-20 - haloperidol 1 mg Tab [REEV],,0250,51079-0734-20,,,
,,,,,,,,,,,,,,,,,"ANCA Screen with MPO and PR3, w/ Reflex to ANCA Titer REF",86021,0300,,263.6,197.7,197.7
,,,,,,,,,,,,,,,,,86021-ADD ON,86021,0300,,263.6,197.7,197.7
,,,,,,,,,,,,,,,,,00338-0072-25 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,00338-0072-25,,,
,,,,,,,,,,,,,,,,,42806-0147-31 - azithromycin 100 mg/5 mL Oral Liq (bottle) [REEV],,0250,42806-0147-31,,,
,,,,,,,,,,,,,,,,,36000-0148-10 - flumazenil 0.1 mg/mL IV Sol MDV [REEV],J3490,0250,36000-0148-10,,,
,,,,,,,,,,,,,,,,,00409-5534-14 - sodium bicarbonate 4.2% IV Sol 10 mL [REEV],,0250,00409-5534-14,,,
,,,,,,,,,,,,,,,,,REEV CT Angio Neck,70498,0352,,"1,345.1",1008.825,1008.825
,,,,,,,,,,,,,,,,,"Calcium, Random Urine with Creatinine REF",82310,0300,,53,39.75,39.75
,,,,,,,,,,,,,,,,,82570 - Creatinine REF,82570,0300,,97.1,72.825,72.825
,,,,,,,,,,,,,,,,,00143-9621-25 - cyanocobalamin 1000 mcg/mL Inj Sol [REEV],J3420,0250,00143-9621-25,,,
,,,,,,,,,,,,,,,,,"21014 Exc face tumor, soft tissue, face/scalp, subfascial 2cm/>",21014,,,,,
,,,,,,,,,,,,,,,,,72611-0765-10 - vancomycin 1 g IV Inj [REEV],J3370,0250,72611-0765-10,,,
,,,,,,,,,,,,,,,,,00527-3219-37 - dantrolene 25 mg Cap [REEV],,0250,00527-3219-37,,,
,,,,,,,,,,,,,,,,,67405-0602-03 - fluconazole 100 mg Tab [REEV],,0250,67405-0602-03,,,
,,,,,,,,,,,,,,,,,68180-0678-01 - oseltamivir 6 mg/mL Pow (bottle) [REEV],,0250,68180-0678-01,,,
,,,,,,,,,,,,,,,,,60687-0446-01 - ibuprofen 400 mg Tab [REEV],,0250,60687-0446-01,,,
,,,,,,,,,,,,,,,,,68382-0309-30 - nitroglycerin 0.2 mg/hr Transderm ER Film [REEV],,0250,68382-0309-30,,,
,,,,,,,,,,,,,,,,,68462-0406-01 - indomethacin 25 mg Cap [REEV],,0250,68462-0406-01,,,
,,,,,,,,,,,,,,,,,76385-0144-01 - hydroxychloroquine 200 mg Tab [REEV],,0250,76385-0144-01,,,
,,,,,,,,,,,,,,,,,60687-0484-01 - pregabalin 50 mg oral capsule [REEV],,0250,60687-0484-01,,,
,,,,,,,,,,,,,,,,,"63323-0462-17 - bupivacaine-epinephrine 0.5%-1:200,000 preservative-free Sol",,0250,63323-0462-17,,,
,,,,,,,,,,,,,,,,,68001-0464-41 - enoxaparin 300 mg/3 mL [REEV],J1650,0250,68001-0464-41,,,
,,,,,,,,,,,,,,,,,72611-0722-25 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,72611-0722-25,,,
,,,,,,,,,,,,,,,,,EA009 Aph Platelets ACDA LR BM>=36h 2,,,,,,
,,,,,,,,,,,,,,,,,EA010 Aph Platelets ACDA LR BM>=36h 3,,,,,,
,,,,,,,,,,,,,,,,,EA007 Aph Platelets ACDA LR BM>=36h,,,,,,
,,,,,,,,,,,,,,,,,EA008 Aph Platelets ACDA LR BM>=36h 1,,,,,,
,,,,,,,,,,,,,,,,,EA139 Aph Plts ACDA>PASC LR BM>=36h 3,,,,,,
,,,,,,,,,,,,,,,,,EA138 Aph Plts ACDA>PASC LR BM>=36h 2,,,,,,
,,,,,,,,,,,,,,,,,EA136 Aph Platelets ACDA>PASC LR BM>=36h,,,,,,
,,,,,,,,,,,,,,,,,EA137 Aph Plts ACDA>PASC LR BM>=36h 1,,,,,,
,,,,,,,,,,,,,,,,,EA017 Aph Plts ACDA Irr LR BM>=36h 2,,,,,,
,,,,,,,,,,,,,,,,,EA018 Aph Plts ACDA Irr LR BM>=36h 3,,,,,,
,,,,,,,,,,,,,,,,,EA015 Aph Platelets ACDA Irr LR BM>=36h,,,,,,
,,,,,,,,,,,,,,,,,EA016 Aph Plts ACDA Irr LR BM>=36h 1,,,,,,
,,,,,,,,,,,,,,,,,EA153 Aph Plts ACDA>PASC IrrLR BM>=36h 1,,,,,,
,,,,,,,,,,,,,,,,,EA154 Aph Plts ACDA>PASC IrrLR BM>=36h 2,,,,,,
,,,,,,,,,,,,,,,,,EA155 Aph Plts ACDA>PASC IrrLR BM>=36h 3,,,,,,
,,,,,,,,,,,,,,,,,EA152 Aph Plts ACDA>PASC Irr LR BM>=36h,,,,,,
,,,,,,,,,,,,,,,,,60687-0569-01 - atropine-diphenoxylate 0.025 mg-2.5 mg Tab [REEV],,0250,60687-0569-01,,,
,,,,,,,,,,,,,,,,,NIHD US APPENDIX,,,,,,
,,,,,,,,,,,,,,,,,68084-0855-01 - baclofen 10 mg Tab UD [REEV],,0250,68084-0855-01,,,
,,,,,,,,,,,,,,,,,"Oxalic Acid, 24 Hour Urine W/O Creatinine REF",83945,0300,,38,28.5,28.5
,,,,,,,,,,,,,,,,,"Uric Acid, 24 Hour Urine W/O Creatinine REF",84560,0300,,37.5,28.125,28.125
,,,,,,,,,,,,,,,,,"Citric Acid, 24 Hour Urine W/O Creatinine REF",82507,0300,,73,54.75,54.75
,,,,,,,,,,,,,,,,,"Sodium, 24 Hour Urine W/O Creatinine REF",84300,0300,,39.7,29.775,29.775
,,,,,,,,,,,,,,,,,"Porphyrins, Fractionated, Quantitative, 24-Hour Urine REF",84120,0300,,49.3,36.975,36.975
,,,,,,,,,,,,,,,,,46122-0108-46 - permethrin topical 1% Creme Rinse Lotion [REEV],,0250,46122-0108-46,,,
,,,,,,,,,,,,,,,,,DISC GRAFIX PL 16MM,,,,611.33,458.4975,458.4975
,,,,,,,,,,,,,,,,,"23930 Incision & Drainage, upper arm or elbow area",23930,,,,,
,,,,,,,,,,,,,,,,,42806-0151-34 - azithromycin 200 mg/5 mL Oral Liq (bottle) [REEV],,0250,42806-0151-34,,,
,,,,,,,,,,,,,,,,,42806-0151-34 - azithromycin 200 mg/5 mL Pow,,0250,42806-0151-34,,,
,,,,,,,,,,,,,,,,,00409-4777-02 - ciprofloxacin 400 mg/200 mL IV Sol [REEV],J0744,0250,00409-4777-02,,,
,,,,,,,,,,,,,,,,,Maternal QUAD Screen REF,81511,0300,,657.1,492.825,492.825
,,,,,,,,,,,,,,,,,71839-0107-01 - DAPTOmycin 500 mg Pow,J0878,0250,71839-0107-01,,,
,,,,,,,,,,,,,,,,,49884-0110-74 - ALPRAZolam 0.25 mg Tab ODT [REEV],,0250,49884-0110-74,,,
,,,,,,,,,,,,,,,,,42023-0221-10 - ertapenem 1 g Inj [REEV],,0250,42023-0221-10,,,
,,,,,,,,,,,,,,,,,Micro Susp. REF,87186,0300,,,,
,,,,,,,,,,,,,,,,,00904-8805-67 - bacitracin/neomycin/polymyxin B Top Oint (pkt) [REEV],,0250,00904-8805-67,,,
,,,,,,,,,,,,,,,,,70860-0121-30 - piperacillin-tazobactam 3 g-0.375 g IV Inj [REEV],J2543,0250,70860-0121-30,,,
,,,,,,,,,,,,,,,,,25021-0101-67 - ceFAZolin 1 g Inj [REEV],J0690,0250,25021-0101-67,,,
,,,,,,,,,,,,,,,,,42023-0164-10 - vasopressin 20 units/mL Inj Sol [REEV],,0250,42023-0164-10,,,
,,,,,,,,,,,,,,,,,SUTURE ETHIBOND XTRA 2-0 CT-1/30IN,,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,"58301 Removal, intrauterine device (IUD)",58301,,,,,
,,,,,,,,,,,,,,,,,"11982 Removal, non-biodegradable drug delivery implant",11982,,,,,
,,,,,,,,,,,,,,,,,Gastrointestinal pathogens,0097U,0300,,953,714.75,714.75
,,,,,,,,,,,,,,,,,DRAPE ROBOTICS WITH LEGGINGS AND POUCH,,,,41.2,30.9,30.9
,,,,,,,,,,,,,,,,,HIGH FLOW DISPOSABLE PATIENT CIRCUIT,,,,,,
,,,,,,,,,,,,,,,,,Systemic Autoimmune Panel 1 REF,86038,0300,,155.5,116.625,116.625
,,,,,,,,,,,,,,,,,86255-ADD ON,86255,0300,,116.9,87.675,87.675
,,,,,,,,,,,,,,,,,86235-ADD ON,86235,0300,,155.5,116.625,116.625
,,,,,,,,,,,,,,,,,86160-ADD ON,86160,0300,,141.2,105.9,105.9
,,,,,,,,,,,,,,,,,86147-ADD ON,86147,0300,,116.9,87.675,87.675
,,,,,,,,,,,,,,,,,86146-ADD ON,86146,0300,,176.4,132.3,132.3
,,,,,,,,,,,,,,,,,83520-ADD ON,83520,0300,,151.1,113.325,113.325
,,,,,,,,,,,,,,,,,86200-ADD ON,86200,0300,,202.9,152.175,152.175
,,,,,,,,,,,,,,,,,86376-ADD ON,86376,0300,,186.4,139.8,139.8
,,,,,,,,,,,,,,,,,Stone Risk Diagnostic Profile 24 HR Urine REF,82140,0300,,137.9,103.425,103.425
,,,,,,,,,,,,,,,,,82340-ADD ON,82340,0300,,18.5,13.875,13.875
,,,,,,,,,,,,,,,,,82507-ADD ON,82507,0300,,73,54.75,54.75
,,,,,,,,,,,,,,,,,82570-ADD ON,82570,0300,,97.1,72.825,72.825
,,,,,,,,,,,,,,,,,83735-ADD ON,83735,0300,,115.9,86.925,86.925
,,,,,,,,,,,,,,,,,83945-ADD ON,83945,0300,,38,28.5,28.5
,,,,,,,,,,,,,,,,,83986-ADD ON,83986,0300,,28.4,21.3,21.3
,,,,,,,,,,,,,,,,,84105-ADD ON,84105,0300,,15.2,11.4,11.4
,,,,,,,,,,,,,,,,,84133-ADD ON,84133,0300,,92.7,69.525,69.525
,,,,,,,,,,,,,,,,,84300-ADD ON,84300,0300,,39.7,29.775,29.775
,,,,,,,,,,,,,,,,,84392-ADD ON,84392,0300,,14.5,10.875,10.875
,,,,,,,,,,,,,,,,,84560-ADD ON,84560,0300,,37.5,28.125,28.125
,,,,,,,,,,,,,,,,,70860-0701-03 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,70860-0701-03,,,
,,,,,,,,,,,,,,,,,63323-0265-30 - methylPREDNISolone 1 g Pow [REEV],J2930,0250,63323-0265-30,,,
,,,,,,,,,,,,,,,,,61755-0039-01 - casirivimab-imdevimab 600mg/5ml-600mg/5 ml Sol [REEV],,0250,61755-0039-01,,,
,,,,,,,,,,,,,,,,,63323-0093-30 - sodium chloride 23.4% 23.4 % Soln-IV,,0250,63323-0093-30,,,
,,,,,,,,,,,,,,,,,59899 Other Procedures for Maternity Care/Delivery,59899,,,,,
,,,,,,,,,,,,,,,,,00409-9094-22 - fentaNYL 0.05 mg/mL Inj Sol [REEV],J3010,0250,00409-9094-22,,,
,,,,,,,,,,,,,,,,,49884-0256-01 - minoxidil 2.5 mg Tab [REEV],,0250,49884-0256-01,,,
,,,,,,,,,,,,,,,,,00641-6014-10 - diltiazem 5 mg/mL IV Sol [REEV],J3490,0250,00641-6014-10,,,
,,,,,,,,,,,,,,,,,71288-0410-83 - enoxaparin 40 mg/0.4 mL UD inj [REEV],J1650,0250,71288-0410-83,,,
,,,,,,,,,,,,,,,,,65862-0107-01 - zidovudine 100 mg Cap [REEV],,0250,65862-0107-01,,,
,,,,,,,,,,,,,,,,,Respiratory Viral Panel REF,87635,0300,,285.3,213.975,213.975
,,,,,,,,,,,,,,,,,87633-ADD ON,87633,0300,,"1,094.1",820.575,820.575
,,,,,,,,,,,,,,,,,CUFF BP DISP (GE) SMALL ADULT,,,,7.4,5.55,5.55
,,,,,,,,,,,,,,,,,CUFF BP DISP (GE) LARGE ADULT,,,,8.98,6.735,6.735
,,,,,,,,,,,,,,,,,CUFF BP DISP(GE) REG ADULT,,,,7.4,5.55,5.55
,,,,,,,,,,,,,,,,,CUFF BP DISP (GE) ADULT FOREARM,,,,9.45,7.0875,7.0875
,,,,,,,,,,,,,,,,,00069-0209-10 - propofol 10 mg/mL 20 mL IV Emul [REEV],J2704,0250,00069-0209-10,,,
,,,,,,,,,,,,,,,,,KIT SPECIMEN MIDSTREAM(MEDLINE SUB),,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,COLLAR (MED) CERVICAL MEDLINE,,,,9.1,6.825,6.825
,,,,,,,,,,,,,,,,,56740 Remove vagina gland lesion,56740,,,,,
,,,,,,,,,,,,,,,,,23155-0601-41 - midazolam 25 mg/5mL Inj Sol [REEV],J2250,0250,23155-0601-41,,,
,,,,,,,,,,,,,,,,,00409-4699-24 - propofol 10 mg/mL 100 mL IV Emul [REEV],J2704,0250,00409-4699-24,,,
,,,,,,,,,,,,,,,,,Salmonella And Shigella,87045,0300,,54.4,40.8,40.8
,,,,,,,,,,,,,,,,,CIRCUIT PASSIVE ADULT( TRI-ANIM),,,,42.69,32.0175,32.0175
,,,,,,,,,,,,,,,,,42023-0146-25 - dexmedetomidine 100 mcg/mL Sol {REEV},,0250,42023-0146-25,,,
,,,,,,,,,,,,,,,,,"Cortisol, Free and Cortisone Urine with Creatinine REF",82530,0300,,233.8,175.35,175.35
,,,,,,,,,,,,,,,,,"83789-Cortisol, Free and Cortisone Urine with Creatinine REF",83789,0300,,202.9,152.175,152.175
,,,,,,,,,,,,,,,,,Glucose Urine FSI,82945,0300,,53,39.75,39.75
,,,,,,,,,,,,,,,,,57237-0224-01 - ramipril 5 mg Cap,,0250,57237-0224-01,,,
,,,,,,,,,,,,,,,,,00574-0520-08 - charcoal-sorbitol 50 g Oral Susp 240 mL [REEV],,0250,00574-0520-08,,,
,,,,,,,,,,,,,,,,,60687-0315-21 - captopril 25 mg Tab [REEV],,0250,60687-0315-21,,,
,,,,,,,,,,,,,,,,,62332-0042-30 - irbesartan 150 mg Tab [REEV],,0250,62332-0042-30,,,
,,,,,,,,,,,,,,,,,61748-0012-06 - pyrazinamide 500 mg Tab [REEV],,0250,61748-0012-06,,,
,,,,,,,,,,,,,,,,,COLLAR CERVICAL LG(MEDLINE),,,,8.95,6.7125,6.7125
,,,,,,,,,,,,,,,,,00031-2235-13 - brompheniramine-phenylephrine 1 mg-2.5 mg/5 mL oral Liq 118 mL [REEV],,0250,00031-2235-13,,,
,,,,,,,,,,,,,,,,,CUFF BP(GE) CHILD REUSABLE,,,,27.38,20.535,20.535
,,,,,,,,,,,,,,,,,CUFF BP(GE) BLUE SMALL ADULT REUSABLE,,,,32.38,24.285,24.285
,,,,,,,,,,,,,,,,,CUFF BP(GE)REGULAR ADULT BLACK REUSABLE,,,,32.38,24.285,24.285
,,,,,,,,,,,,,,,,,BREATHING CIRCUIT SET(HAMILTON),,,,93.72,70.29,70.29
,,,,,,,,,,,,,,,,,KIT PROBE COVER ULTRASOUND SET,,,,21.72,16.29,16.29
,,,,,,,,,,,,,,,,,CUFF(GE)ADULT LONG NAVY BP REUSABLE,,,,,,
,,,,,,,,,,,,,,,,,63807-0100-01 - sodium chloride 0.9% Sol,,0250,63807-0100-01,,,
,,,,,,,,,,,,,,,,,63323-0012-10 - oxytocin 10 units/mL Inj Sol [REEV],J2590,0250,63323-0012-10,,,
,,,,,,,,,,,,,,,,,.Thyroglobulin REF,84432,0300,,92.7,69.525,69.525
,,,,,,,,,,,,,,,,,"73562-0115-01 - pancrelipase 5000 units-17,000 units-24,000 units Cap [REEV]",,0250,73562-0115-01,,,
,,,,,,,,,,,,,,,,,46122-0615-76 - aspirin 81 mg Oral EC Tab [REEV],,0250,46122-0615-76,,,
,,,,,,,,,,,,,,,,,"49281-0721-10 - influenza virus vaccine, inactivated recombinant hemagglutinin quadrivalent Sol [REE",,0250,49281-0721-10,,,
,,,,,,,,,,,,,,,,,"49281-0121-65 - influenza virus vaccine, inactivated high-dose preservative-free trivalent Sus [REEV",,0250,49281-0121-65,,,
,,,,,,,,,,,,,,,,,"49281-0635-15 - influenza virus vaccine, inactivated quadrivalent Sus [REEV]",,0250,49281-0635-15,,,
,,,,,,,,,,,,,,,,,67457-0855-02 - adenosine 3 mg/mL IV Sol [REEV],J0153,0250,67457-0855-02,,,
,,,,,,,,,,,,,,,,,BETADINE SWAB STICK (3-PACK) MEDLINE,,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,BETADINE SWAB STICK (1-PACK) MEDLINE,,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,71288-0422-96 - heparin 5000 units/mL Inj Sol [REEV],J1644,0250,71288-0422-96,,,
,,,,,,,,,,,,,,,,,68180-0984-30 - budesonide 0.5 mg/2 mL Sus,J7633,0250,68180-0984-30,,,
,,,,,,,,,,,,,,,,,14.3.3 eta Protein REF,83520,0300,,184.2,138.15,138.15
,,,,,,,,,,,,,,,,,00409-3365-10 - HYDROmorphone 2 mg/mL Inj Sol [REEV],,0250,00409-3365-10,,,
,,,,,,,,,,,,,,,,,SPLINT FINGER BASEBALL SMALL(MEDLINE),,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,URINE PEDI COLLECTOR(MEDLINE),,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,63323-0983-21 - piperacillin-tazobactam 3 g-0.375 g IV Inj [REEV],J2543,0250,63323-0983-21,,,
,,,,,,,,,,,,,,,,,68001-0381-00 - labetalol 100 mg Tab [REEV],,0250,68001-0381-00,,,
,,,,,,,,,,,,,,,,,68001-0376-68 - DAPTOmycin 500 mg Pow Inj [REEV],J0878,0250,68001-0376-68,,,
,,,,,,,,,,,,,,,,,00536-1008-36 - aspirin 81 mg Chew Tab [REEV],,0250,00536-1008-36,,,
,,,,,,,,,,,,,,,,,60687-0152-01 - cephalexin 250 mg Cap [REEV],,0250,60687-0152-01,,,
,,,,,,,,,,,,,,,,,"59121 Surgical treatment of ectopic pregnancy, w/o salpingectomy and/or oophorectomy",59121,,,,,
,,,,,,,,,,,,,,,,,"59136 Surgical treatment of ectopic pregnancy, interstitial, uterine pregnancy w/partial resection o",59136,,,,,
,,,,,,,,,,,,,,,,,"59150 Laparoscopic treatment of ectopic pregnancy, w/o salpingectomy and/or oophorectomy",59150,,,,,
,,,,,,,,,,,,,,,,,59871 Remove cerclage suture,59871,,,,,
,,,,,,,,,,,,,,,,,ATHLETIC SUPPORTER LARGE,,,,24.76,18.57,18.57
,,,,,,,,,,,,,,,,,ATHLETIC SUPPORTER MEDIUM,,,,25.55,19.1625,19.1625
,,,,,,,,,,,,,,,,,ATHLETIC SUPPORTER SMALL,,,,24.76,18.57,18.57
,,,,,,,,,,,,,,,,,65862-0677-01 - ALPRAZolam 0.5 mg Tab [REEV],,0250,65862-0677-01,,,
,,,,,,,,,,,,,,,,,00904-5046-61 - captopril 25 mg Tab [REEV],,0250,00904-5046-61,,,
,,,,,,,,,,,,,,,,,COLLAR PHILADELPHIA(SMALL)MEDLINE,,,,26.07,19.5525,19.5525
,,,,,,,,,,,,,,,,,00143-9837-01 - Penicillin V Potassium 250 mg Tab [REEV],,0250,00143-9837-01,,,
,,,,,,,,,,,,,,,,,70860-0301-10 - diltiazem 5 mg/mL IV Sol [REEV],J3490,0250,70860-0301-10,,,
,,,,,,,,,,,,,,,,,72611-0756-10 - rocuronium 10 mg/mL IV Sol [REEV],,0250,72611-0756-10,,,
,,,,,,,,,,,,,,,,,42494-0301-12 - hydrocortisone 25 mg Supp [REEV],,0250,42494-0301-12,,,
,,,,,,,,,,,,,,,,,00548-5400-00 - medroxyPROGESTERone 150 mg/mL IM Susp [REEV],J1050,0250,00548-5400-00,,,
,,,,,,,,,,,,,,,,,60687-0575-21 - rifAMPin 150 mg Cap,,0250,60687-0575-21,,,
,,,,,,,,,,,,,,,,,60687-0504-01 - verapamil 180 mg ER Tab [REEV],,0250,60687-0504-01,,,
,,,,,,,,,,,,,,,,,50111-0787-66 - azithromycin 250 mg Tab [REEV],,0250,50111-0787-66,,,
,,,,,,,,,,,,,,,,,"19020 Incision, breast lesion ProFee",19020,,,,,
,,,,,,,,,,,,,,,,,"54700 I&D, epididymis, testis and/or scrotal space",54700,,,,,
,,,,,,,,,,,,,,,,,"55040 Excision, hydrocele, unilateral",55040,,,,,
,,,,,,,,,,,,,,,,,"11404 Excision, benign lesion, trunk, arms, legs, 3.1 to 4 cm",11404,0521,,,,
,,,,,,,,,,,,,,,,,"58160-0812-52 - diphtheria/pertussis,acel/tetanus/polio - Sus",,0259,58160-0812-52,,,
,,,,,,,,,,,,,,,,,"49020 Drainage, peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess",49020,,,,,
,,,,,,,,,,,,,,,,,Amino Acid Analysis for MSUD REF,82136,0300,,251.1,188.325,188.325
,,,,,,,,,,,,,,,,,PENCIL CAUTERY COVIDIEN,,,,25.73,19.2975,19.2975
,,,,,,,,,,,,,,,,,43066-0026-10 - niCARdipine 20 mg/200 mL-NaCl 0.86% Soln-IV,,0250,43066-0026-10,,,
,,,,,,,,,,,,,,,,,25021-0500-02 - thiamine 100 mg/mL Inj Sol [REEV],J3411,0250,25021-0500-02,,,
,,,,,,,,,,,,,,,,,69339-0136-34 - diazepam 5 mg/mL Inj Sol [REEV],J3360,0250,69339-0136-34,,,
,,,,,,,,,,,,,,,,,"49250 Excision, umbilicus",49250,,,,,
,,,,,,,,,,,,,,,,,KIT MIDSTREAM(FISHER),,,,7.69,5.7675,5.7675
,,,,,,,,,,,,,,,,,NASOPHARYNGEAL AIRWAY 36FR(SUB),,,,14.47,10.8525,10.8525
,,,,,,,,,,,,,,,,,RSV NAAT FSI,87634,0300,,157.5,118.125,118.125
,,,,,,,,,,,,,,,,,00555-0159-02 - chlordiazePOXIDE 25 mg Cap,,0250,00555-0159-02,,,
,,,,,,,,,,,,,,,,,70594-0034-02 - DAPTOmycin 500 mg Pow Inj [REEV],J0878,0250,70594-0034-02,,,
,,,,,,,,,,,,,,,,,70860-0751-02 - famotidine 10 mg/mL Sol inj [REEV],,0250,70860-0751-02,,,
,,,,,,,,,,,,,,,,,IA-2 Antibody REF,86341,0300,,163.8,122.85,122.85
,,,,,,,,,,,,,,,,,GEL ULTRASOUND STERILE PACKETS,,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,CATHETER 12FR HIGH PRESSURE 16CM CURVED EXT KIT,,,,162.22,121.665,121.665
,,,,,,,,,,,,,,,,,Strep A NAAT FSI,87651,0300,,105,78.75,78.75
,,,,,,,,,,,,,,,,,"63323-0489-17 - epinephrine-lidocaine 1:200,000-2% preservative-free Sol [REEV]",,0250,63323-0489-17,,,
,,,,,,,,,,,,,,,,,"Weight Loss, Initial",,0509,,194.3,145.725,145.725
,,,,,,,,,,,,,,,,,"Weight Loss, FollowUp",,0509,,105,78.75,78.75
,,,,,,,,,,,,,,,,,"Weight Loss, Booster",,0509,,105,78.75,78.75
,,,,,,,,,,,,,,,,,"21011 Excision, tumor, soft tissue of face or scalp, subcu, <2 cm",21011,,,,,
,,,,,,,,,,,,,,,,,"21012 Excision, tumor, soft tissue of face or scalp, subcu, 2 cm or greater",21012,,,,,
,,,,,,,,,,,,,,,,,"10080 I&D, pilonidal cyst, simple",10080,0521,,,,
,,,,,,,,,,,,,,,,,"10081 I&D, pilonidal cyst, complicated",10081,0521,,,,
,,,,,,,,,,,,,,,,,00904-6794-89 - aspirin 81 mg Chew Tab [REEV],,0250,00904-6794-89,,,
,,,,,,,,,,,,,,,,,51672-2116-02 - acetaminophen 325 mg Supp [REEV],,0250,51672-2116-02,,,
,,,,,,,,,,,,,,,,,70069-0261-01 - nitroprusside 25 mg/mL IV Sol [REEV],,0250,70069-0261-01,,,
,,,,,,,,,,,,,,,,,63323-0486-26 - lidocaine 2% 20 mL MDV Sol [REEV],J2001,0250,63323-0486-26,,,
,,,,,,,,,,,,,,,,,TRAY CATHETER(NON-LATEX)18FR-CARDINAL,,,,22.35,16.7625,16.7625
,,,,,,,,,,,,,,,,,FETAL MONITOR BELT(CARDINAL),,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,63323-0261-10 - progesterone 50 mg/mL IM Sol [REEV],J2675,0250,63323-0261-10,,,
,,,,,,,,,,,,,,,,,63323-0162-01 - ketorolac 30 mg/mL Inj Sol [REEV],J1885,0250,63323-0162-01,,,
,,,,,,,,,,,,,,,,,27241-0139-09 - oseltamivir 6 mg/mL Pow (bottle) [REEV],,0250,27241-0139-09,,,
,,,,,,,,,,,,,,,,,27241-0139-09 - oseltamivir 6 mg/mL Pow DOSE [REEV],,0250,27241-0139-09,,,
,,,,,,,,,,,,,,,,,68180-0166-13 - vancomycin 125 mg Cap [REEV],,0250,68180-0166-13,,,
,,,,,,,,,,,,,,,,,"Aesthetics, Botox",,0509,,720.3,540.225,540.225
,,,,,,,,,,,,,,,,,"Aesthetics, Juvederm",,0509,,710.9,533.175,533.175
,,,,,,,,,,,,,,,,,60687-0370-01 - methIMAzole 10 mg Tab UD [REEV],,0250,60687-0370-01,,,
,,,,,,,,,,,,,,,,,49281-0511-05 - diphth/haemophilus/pertussis/tetanus/polio inj (PHS) [REEV],,0250,49281-0511-05,,,
,,,,,,,,,,,,,,,,,Acylcarnitine REF,82017,0300,,129,96.75,96.75
,,,,,,,,,,,,,,,,,SPLINT WRIST RT-LG(MEDLINE),,,,15.72,11.79,11.79
,,,,,,,,,,,,,,,,,25021-0139-10 - nafcillin 1 g Inj [REEV],,0250,25021-0139-10,,,
,,,,,,,,,,,,,,,,,"27339 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular), 5 cm or gr",27339,,,,,
,,,,,,,,,,,,,,,,,00115-9931-78 - levalbuterol 0.63 mg/3 mL Inh Sol [REEV],J7614,0250,00115-9931-78,,,
,,,,,,,,,,,,,,,,,TUBE LEVIN12FR(SUB),,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,KIT(MEDLINE SUB#2)MIDSTREAM,,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,KIT(MEDLINE SUB#3)MIDSTREAM,,,,7.86,5.895,5.895
,,,,,,,,,,,,,,,,,55150-0242-51 - linezolid 2 mg/mL-D5% Sol [REEV],J2020,0250,55150-0242-51,,,
,,,,,,,,,,,,,,,,,"64505 Injection, anesthetic agent; sphenopalatine ganglion;",64505,,,,,
,,,,,,,,,,,,,,,,,SHOE POST OP MEDIUM(MEDLINE)MEN,,,,24,18,18
,,,,,,,,,,,,,,,,,57664-0683-57 - linezolid 600mg/300mL IV Sol [REEV],J2020,0250,57664-0683-57,,,
,,,,,,,,,,,,,,,,,60687-0640-01 - metFORMIN 500 mg ER Tab [REEV],,0250,60687-0640-01,,,
,,,,,,,,,,,,,,,,,00904-7162-61 - metFORMIN 500 mg Tab [REEV],,0250,00904-7162-61,,,
,,,,,,,,,,,,,,,,,"Mycoplasma pneumoniae DNA, Qualitative, PCR REF",87581,0300,,120.12,90.09,90.09
,,,,,,,,,,,,,,,,,"Drug Monitoring, Barbiturates, w/Confirmation REF",80307,0300,,155.3,116.475,116.475
,,,,,,,,,,,,,,,,,"Drug Monitoring, Methadone Metabolite w/Confirmation REF",80307,0300,,155.35,116.5125,116.5125
,,,,,,,,,,,,,,,,,"Drug Monitoring, Phencyclidine, w/Confirmation REF",80307,0300,,155.35,116.5125,116.5125
,,,,,,,,,,,,,,,,,"Drug Monitoring, Fentanyl, w/Confirmation REF",80307,0300,,155.35,116.5125,116.5125
,,,,,,,,,,,,,,,,,55150-0252-20 - lidocaine 1% 20 mL MDV Inj Sol [REEV],J2001,0250,55150-0252-20,,,
,,,,,,,,,,,,,,,,,50111-0787-51 - azithromycin 250 mg Tab,,0250,50111-0787-51,,,
,,,,,,,,,,,,,,,,,Calcium Random Urine W/O Creatinine REF,82310,0300,,50.4,37.8,37.8
,,,,,,,,,,,,,,,,,Phosphate Random Urine W/O Creatinine REF,84105,0300,,14.45,10.8375,10.8375
,,,,,,,,,,,,,,,,,DRAPE GENERAL ENDOSCOPY(9458),,,,29.14,21.855,21.855
,,,,,,,,,,,,,,,,,DRAPE LAPAROTOMY TRANSVERSE(29421),,,,16.41,12.3075,12.3075
,,,,,,,,,,,,,,,,,DRAPE MOBILE X-RAY C-ARM,,,,38.47,28.8525,28.8525
,,,,,,,,,,,,,,,,,CATHETER INTRADUCER TAUT,,,,37.68,28.26,28.26
,,,,,,,,,,,,,,,,,CATHETER 4.5FR CHOLANGIOGRAM TAUT,,,,91.5,68.625,68.625
,,,,,,,,,,,,,,,,,MASK AEROSOL ADJ NOSE STRAP(PEDI),,,,5,3.75,3.75
,,,,,,,,,,,,,,,,,"11626 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11626,0960,,"1,042",781.5,781.5
,,,,,,,,,,,,,,,,,56605 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION ProFee,56605,0960,,290,217.5,217.5
,,,,,,,,,,,,,,,,,57454 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX ProFee,57454,0960,,394,295.5,295.5
,,,,,,,,,,,,,,,,,58300 INSERTION OF INTRAUTERINE DEVICE (IUD) ProFee,58300,0960,,203,152.25,152.25
,,,,,,,,,,,,,,,,,99222 LEVEL 2 ADMIT MODERATE 50 MIN ProFee,99222,0987,,290,217.5,217.5
,,,,,,,,,,,,,,,,,99223 LEVEL 3 HIGHLY COMPLEX 70 MIN ProFee,99223,0987,,348,261,261
,,,,,,,,,,,,,,,,,99234 LEVEL 1: DETAILED HX/EXAM: STRAIGHTFORWARD SAME DAY 40 MIN ProFee,99234,0987,,290,217.5,217.5
,,,,,,,,,,,,,,,,,99235 LEVEL 2: COMP HX/EXAM: MODERATE SAME DAY 50 MIN ProFee,99235,0987,,348,261,261
,,,,,,,,,,,,,,,,,99236 LEVEL 3: COMP HX/EXAM: HIGH SAME DAY 55 MIN ProFee,99236,0987,,463,347.25,347.25
,,,,,,,,,,,,,,,,,99238 HSP DISCH DAY MGMT 30 MIN ProFee,99238,0987,,151,113.25,113.25
,,,,,,,,,,,,,,,,,99239 INPT DSCHRG >30 MIN ProFee,99239,0987,,197,147.75,147.75
,,,,,,,,,,,,,,,,,99251 INTL INPT CNSLT 20MIN/STFOWARD ProFee,99251,0987,,185,138.75,138.75
,,,,,,,,,,,,,,,,,99252 INTL INPT CNSLT 40MINS/STFOWARD ProFee,99252,0987,,232,174,174
,,,,,,,,,,,,,,,,,99255 INTL INPT CNSLT 110MIN/H ProFee,99255,0987,,417,312.75,312.75
,,,,,,,,,,,,,,,,,99283 ED PF - Level 3,99283,0981,,267,200.25,200.25
,,,,,,,,,,,,,,,,,99284 ED PF - Level 4,99284,0981,,348,261,261
,,,,,,,,,,,,,,,,,99285 ED PF - Level 5,99285,0981,,522,391.5,391.5
,,,,,,,,,,,,,,,,,00402 BREAST AUGMEN/REDUCTION ProFee,00402,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00450 PROC CLAVICLE AND SCAPULA ProFee,00450,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00532 ACCESS CENTRAL VENOUS CIR ProFee,00532,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00832 VENTRAL INCISIONAL HERNIA ProFee,00832,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00846 HYSTERECTOMY ProFee,00846,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00860 EXTRAPERITONEAL LOWER ABD ProFee,00860,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00862 RENAL PROC1/3URETER/DONOR ProFee,00862,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00910 TRANSURETHRAL PROC URETHR ProFee,00910,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00914 TRANSURETH RESECT PROSTAT ProFee,00914,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00918 PERINEAL PROC W/ FRAG MAN ProFee,00918,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00926 RADICAL ORCHIECTOMY INGUI ProFee,00926,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00930 ORCHIOPEXY UNI OR BILATER ProFee,00930,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00940 VAG PROCEDURES INCL BIOPS ProFee,00940,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00944 VAGINAL HYSTERECTOMY ProFee,00944,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01112 BONE MARROW ASPIRATION BX ProFee,01112,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01200 CLOSED PROC HIP JOINT ProFee,01200,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01220 ANES CLSD UPPER 2/3 FEMUR ProFee,01220,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"01250 NERVES,MUSC,TENDON,FASCIA ProFee",01250,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01260 VEIN UPPER LEG INC EXPLOR ProFee,01260,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01340 ANES OPN PROC LWER 1/3FEM ProFee,01340,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01360 OPEN PROC LOWER 1/3 FEMUR ProFee,01360,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01380 CLSD KNEE ARTHROSCOPY ProFee,01380,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01462 CLSD PROC ANKLE LOWER LEG ProFee,01462,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01470 PROC NER MUS TEN LOW LEG ProFee,01470,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01610 PROC NERVE MUSC SHLDR AXI ProFee,01610,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01620 CLSD PROC SHOULDER JOINT ProFee,01620,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01730 CLSD PROC HUMERUS ELBOW ProFee,01730,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01770 ANES PROC ART UP/ARM ELBO ProFee,01770,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01780 VEINS UPPER ARM AND ELBOW ProFee,01780,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"01820 CLSD PROC WRIST,HAND ProFee",01820,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"01840 PROC ARTER FOREARM,WRIST ProFee",01840,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01844 VASCULAR SHUNT REVISION ProFee,01844,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01960 VAGINAL DELIVERY ProFee,01960,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01961 CESAREAN DELIVERY ProFee,01961,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01962 ANES FOR URNT HYSTO F/DEL ProFee,01962,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01965 INCOMPLETE/MISSED ABORTIO ProFee,01965,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01967 LABOR ANALGESIA/VAG DELIV ProFee,01967,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01968 CES DEL AFTR LABR ANALGESIA ProFee,01968,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01969 CES HYST AFTR LABR ANL/AN ProFee,01969,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01991 ANES NERVE BLOCK/INJ ProFee,01991,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01992 PRONE POSITION ProFee,01992,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01996 DAILY HOSP MGMNT EPIDURL ProFee,01996,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE ProFee,10021,0960,,808.2,606.15,606.15
,,,,,,,,,,,,,,,,,"10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS O ProFee",10060,0960,,575.5,431.625,431.625
,,,,,,,,,,,,,,,,,"10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS O ProFee",10061,0960,,638.4,478.8,478.8
,,,,,,,,,,,,,,,,,10081 INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED ProFee,10081,0960,,"1,370.5",1027.875,1027.875
,,,,,,,,,,,,,,,,,"10120 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE ProFee",10120,0960,,"1,325.2",993.9,993.9
,,,,,,,,,,,,,,,,,"11004 DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSU ProFee",11004,0960,,"2,198.4",1648.8,1648.8
,,,,,,,,,,,,,,,,,"11104 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), ProFee",,0960,,477.5,358.125,358.125
,,,,,,,,,,,,,,,,,"11200 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 L ProFee",11200,0960,,255.8,191.85,191.85
,,,,,,,,,,,,,,,,,"11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAM ProFee",11300,0960,,526,394.5,394.5
,,,,,,,,,,,,,,,,,"11311 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, ProFee",11311,0960,,598.8,449.1,449.1
,,,,,,,,,,,,,,,,,"11313 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, ProFee",11313,0960,,998.9,749.175,749.175
,,,,,,,,,,,,,,,,,"11400 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11400,0960,,664.9,498.675,498.675
,,,,,,,,,,,,,,,,,"11401 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11401,0960,,710.1,532.575,532.575
,,,,,,,,,,,,,,,,,"11402 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11402,0960,,739.9,554.925,554.925
,,,,,,,,,,,,,,,,,"11403 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11403,0960,,932.8,699.6,699.6
,,,,,,,,,,,,,,,,,"11404 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11404,0960,,830.3,622.725,622.725
,,,,,,,,,,,,,,,,,"11406 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11406,0960,,"1,250.3",937.725,937.725
,,,,,,,,,,,,,,,,,"11421 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11421,0960,,414.6,310.95,310.95
,,,,,,,,,,,,,,,,,"11422 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11422,0960,,784,588,588
,,,,,,,,,,,,,,,,,"11423 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11423,0960,,797.2,597.9,597.9
,,,,,,,,,,,,,,,,,"11424 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11424,0960,,"1,250.3",937.725,937.725
,,,,,,,,,,,,,,,,,"11426 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), ProFee",11426,0960,,"1,335.2",1001.4,1001.4
,,,,,,,,,,,,,,,,,"11441 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11441,0960,,516,387,387
,,,,,,,,,,,,,,,,,"11442 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11442,0960,,837.9,628.425,628.425
,,,,,,,,,,,,,,,,,"11443 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11443,0960,,768.5,576.375,576.375
,,,,,,,,,,,,,,,,,"11444 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11444,0960,,"1,374.9",1031.175,1031.175
,,,,,,,,,,,,,,,,,"11446 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWH ProFee",11446,0960,,"1,437.7",1078.275,1078.275
,,,,,,,,,,,,,,,,,"11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR IN ProFee",11450,0960,,"1,427.8",1070.85,1070.85
,,,,,,,,,,,,,,,,,"11601 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0 ProFee",11601,0960,,"1,229.4",922.05,922.05
,,,,,,,,,,,,,,,,,"11606 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER O ProFee",11606,0960,,"1,514.9",1136.175,1136.175
,,,,,,,,,,,,,,,,,"11621 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11621,0960,,"1,115.8",836.85,836.85
,,,,,,,,,,,,,,,,,"11622 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11622,0960,,"1,381.5",1036.125,1036.125
,,,,,,,,,,,,,,,,,"11623 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11623,0960,,"1,097.1",822.825,822.825
,,,,,,,,,,,,,,,,,"11624 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXC ProFee",11624,0960,,944.9,708.675,708.675
,,,,,,,,,,,,,,,,,"11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE ProFee",11730,0960,,462,346.5,346.5
,,,,,,,,,,,,,,,,,11770 EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE ProFee,11770,0960,,"1,403.6",1052.7,1052.7
,,,,,,,,,,,,,,,,,11771 EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE ProFee,11771,0960,,"2,302.1",1726.575,1726.575
,,,,,,,,,,,,,,,,,11772 EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED ProFee,11772,0960,,"2,802.6",2101.95,2101.95
,,,,,,,,,,,,,,,,,11971 REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS ProFee,11971,0960,,"1,736.5",1302.375,1302.375
,,,,,,,,,,,,,,,,,"11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT ProFee",11981,0960,,442.2,331.65,331.65
,,,,,,,,,,,,,,,,,"12001 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK ProFee",12001,0960,,491.8,368.85,368.85
,,,,,,,,,,,,,,,,,"12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS M ProFee",12011,0960,,475.3,356.475,356.475
,,,,,,,,,,,,,,,,,"12032 REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HA ProFee",12032,0960,,"1,113.6",835.2,835.2
,,,,,,,,,,,,,,,,,"12053 REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANE ProFee",12053,0960,,"1,600.9",1200.675,1200.675
,,,,,,,,,,,,,,,,,"13121 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM ProFee",13121,0960,,"1,559",1169.25,1169.25
,,,,,,,,,,,,,,,,,"15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ CM OR ProFee",15200,0960,,"3,181.9",2386.425,2386.425
,,,,,,,,,,,,,,,,,"15240 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, ProFee",15240,0960,,"2,981.2",2235.9,2235.9
,,,,,,,,,,,,,,,,,"15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA ProFee",15839,0960,,"3,411.2",2558.4,2558.4
,,,,,,,,,,,,,,,,,"17106 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS TH ProFee",17106,0960,,"1,195.2",896.4,896.4
,,,,,,,,,,,,,,,,,"17110 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CU ProFee",17110,0960,,509.4,382.05,382.05
,,,,,,,,,,,,,,,,,"19101 BIOPSY OF BREAST; OPEN, INCISIONAL ProFee",19101,0960,,"1,659.4",1244.55,1244.55
,,,,,,,,,,,,,,,,,"19120 EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TI ProFee",19120,0960,,"1,884.3",1413.225,1413.225
,,,,,,,,,,,,,,,,,"19301 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); ProFee",19301,0960,,"2,334.1",1750.575,1750.575
,,,,,,,,,,,,,,,,,"19302 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH A ProFee",19302,0960,,"3,608.6",2706.45,2706.45
,,,,,,,,,,,,,,,,,20103 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY ProFee,20103,0960,,"2,218.3",1663.725,1663.725
,,,,,,,,,,,,,,,,,"20610 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, ProFee",20610,0960,,468.7,351.525,351.525
,,,,,,,,,,,,,,,,,"21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX ProFee",21550,0960,,"1,065.1",798.825,798.825
,,,,,,,,,,,,,,,,,"21556 EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR ProFee",21556,0960,,"1,970.3",1477.725,1477.725
,,,,,,,,,,,,,,,,,"22903 EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER ProFee",22903,0960,,"1,569",1176.75,1176.75
,,,,,,,,,,,,,,,,,"23075 EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM ProFee",23075,0960,,"1,337.4",1003.05,1003.05
,,,,,,,,,,,,,,,,,"23655 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA ProFee",23655,0960,,"1,187.5",890.625,890.625
,,,,,,,,,,,,,,,,,"24071 EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER ProFee",24071,0960,,"1,575.6",1181.7,1181.7
,,,,,,,,,,,,,,,,,"26160 EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLI ProFee",26160,0960,,986.8,740.1,740.1
,,,,,,,,,,,,,,,,,"27045 EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 ProFee",,0960,,"3,001",2250.75,2250.75
,,,,,,,,,,,,,,,,,"27047 EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; LESS THAN 3 CM ProFee",27047,0960,,"1,740.9",1305.675,1305.675
,,,,,,,,,,,,,,,,,"27337 EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER ProFee",27337,0960,,"1,619.7",1214.775,1214.775
,,,,,,,,,,,,,,,,,"27603 INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA ProFee",27603,0960,,"2,023.2",1517.4,1517.4
,,,,,,,,,,,,,,,,,"28150 PHALANGECTOMY, TOE, EACH TOE ProFee",28150,0960,,"1,661.6",1246.2,1246.2
,,,,,,,,,,,,,,,,,"28232 TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE) ProFee",28232,0960,,"1,378.2",1033.65,1033.65
,,,,,,,,,,,,,,,,,"28312 OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; OTHER PHALANGES, ANY TOE ProFee",28312,0960,,"2,093.7",1570.275,1570.275
,,,,,,,,,,,,,,,,,"28810 AMPUTATION, METATARSAL, WITH TOE, SINGLE ProFee",28810,0960,,"1,557.9",1168.425,1168.425
,,,,,,,,,,,,,,,,,"28820 AMPUTATION, TOE; METATARSOPHALANGEAL JOINT ProFee",28820,0960,,"2,251.3",1688.475,1688.475
,,,,,,,,,,,,,,,,,31575 LARYNGOSCOPY FLEXIBLE DIAGNOSTIC ProFee,31575,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"31600 TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); ProFee",31600,0960,,"1,610.8",1208.1,1208.1
,,,,,,,,,,,,,,,,,"31603 TRACHEOSTOMY, EMERGENCY PROCEDURE; TRANSTRACHEAL ProFee",31603,0960,,"1,659.4",1244.55,1244.55
,,,,,,,,,,,,,,,,,"32551 TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFO ProFee",32551,0960,,"1,123.5",842.625,842.625
,,,,,,,,,,,,,,,,,32552 REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF ProFee,32552,0960,,879.8,659.85,659.85
,,,,,,,,,,,,,,,,,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR O ProFee,36556,0960,,"1,225",918.75,918.75
,,,,,,,,,,,,,,,,,"36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS ProFee",36558,0960,,"2,841.2",2130.9,2130.9
,,,,,,,,,,,,,,,,,"36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEO ProFee",36561,0960,,"4,880.9",3660.675,3660.675
,,,,,,,,,,,,,,,,,"36569 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOU ProFee",36569,0960,,994.5,745.875,745.875
,,,,,,,,,,,,,,,,,"36575 REPAIR OF TUNNELED OR NON-TUNNELED CENTRAL VENOUS ACCESS CATHETER, WITHOUT SUBCUTANEOU ProFee",36575,0960,,768.5,576.375,576.375
,,,,,,,,,,,,,,,,,"36589 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP ProFee",36589,0960,,820.3,615.225,615.225
,,,,,,,,,,,,,,,,,"36590 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENT ProFee",36590,0960,,957,717.75,717.75
,,,,,,,,,,,,,,,,,"36600 ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS ProFee",36600,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPAR ProFee",36620,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"37609 LIGATION OR BIOPSY, TEMPORAL ARTERY ProFee",37609,0960,,"1,045.2",783.9,783.9
,,,,,,,,,,,,,,,,,"38500 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL ProFee",38500,0960,,"1,042",781.5,781.5
,,,,,,,,,,,,,,,,,38700 SUPRAHYOID LYMPHADENECTOMY ProFee,38700,0960,,"3,292.1",2469.075,2469.075
,,,,,,,,,,,,,,,,,"40812 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR ProFee",40812,0960,,"1,087.1",815.325,815.325
,,,,,,,,,,,,,,,,,"43235 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF S ProFee",43235,0960,,"1,225",918.75,918.75
,,,,,,,,,,,,,,,,,"43239 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE ProFee",43239,0960,,"1,340.7",1005.525,1005.525
,,,,,,,,,,,,,,,,,"43246 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEO ProFee",43246,0960,,"1,369.3",1026.975,1026.975
,,,,,,,,,,,,,,,,,"43247 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S) ProFee",43247,0960,,"1,531.5",1148.625,1148.625
,,,,,,,,,,,,,,,,,"43250 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), O ProFee",43250,0960,,"1,580",1185,1185
,,,,,,,,,,,,,,,,,"43251 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), O ProFee",43251,0960,,"1,471.9",1103.925,1103.925
,,,,,,,,,,,,,,,,,"43760 CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE ProFee",,0960,,"1,670.4",1252.8,1252.8
,,,,,,,,,,,,,,,,,"43870 CLOSURE OF GASTROSTOMY, SURGICAL ProFee",43870,0960,,"1,048.6",786.45,786.45
,,,,,,,,,,,,,,,,,44005 ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE) ProFee,44005,0960,,"4,411.2",3308.4,3308.4
,,,,,,,,,,,,,,,,,"44120 ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND ANASTOMOSIS ProFee",44120,0960,,"4,929.4",3697.05,3697.05
,,,,,,,,,,,,,,,,,"44143 COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PR ProFee",44143,0960,,"6,290.9",4718.175,4718.175
,,,,,,,,,,,,,,,,,"44145 COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) ProFee",44145,0960,,"6,277.7",4708.275,4708.275
,,,,,,,,,,,,,,,,,"44180 LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDUR ProFee",44180,0960,,"3,670.3",2752.725,2752.725
,,,,,,,,,,,,,,,,,"44204 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS ProFee",44204,0960,,"5,566.6",4174.95,4174.95
,,,,,,,,,,,,,,,,,"44205 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH ILEOCOL ProFee",44205,0960,,"5,297.6",3973.2,3973.2
,,,,,,,,,,,,,,,,,"44208 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW ProFee",44208,0960,,"5,552.2",4164.15,4164.15
,,,,,,,,,,,,,,,,,"44310 ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE ProFee",44310,0975,,"2,873.6",2155.2,2155.2
,,,,,,,,,,,,,,,,,44320 COLOSTOMY OR SKIN LEVEL CECOSTOMY; ProFee,44320,0960,,"3,944.8",2958.6,2958.6
,,,,,,,,,,,,,,,,,"44376 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING I ProFee",44376,0960,,"1,067.3",800.475,800.475
,,,,,,,,,,,,,,,,,"44392 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY H ProFee",44392,0960,,"1,458.7",1094.025,1094.025
,,,,,,,,,,,,,,,,,"44603 SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, I ProFee",44603,0960,,"5,598.5",4198.875,4198.875
,,,,,,,,,,,,,,,,,"44626 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND COLORECTAL ANASTO ProFee",44626,0960,,"5,539",4154.25,4154.25
,,,,,,,,,,,,,,,,,44640 CLOSURE OF INTESTINAL CUTANEOUS FISTULA ProFee,44640,0975,,"3,862.2",2896.65,2896.65
,,,,,,,,,,,,,,,,,44950 APPENDECTOMY; ProFee,44950,0960,,"2,507.1",1880.325,1880.325
,,,,,,,,,,,,,,,,,44955 APPENDECTOMY; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (NOT AS ProFee,44955,0960,,425.6,319.2,319.2
,,,,,,,,,,,,,,,,,"44970 LAPAROSCOPY, SURGICAL, APPENDECTOMY ProFee",44970,0975,,"2,617.4",1963.05,1963.05
,,,,,,,,,,,,,,,,,"45300 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY B ProFee",45300,0960,,677,507.75,507.75
,,,,,,,,,,,,,,,,,"45330 SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING O ProFee",45330,0960,,691.4,518.55,518.55
,,,,,,,,,,,,,,,,,"45331 SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE ProFee",45331,0960,,912.9,684.675,684.675
,,,,,,,,,,,,,,,,,45355 COLSC RGD/FLX TABDL VIA COLOTOMY 1/MLT ProFee,,0960,,839.1,629.325,629.325
,,,,,,,,,,,,,,,,,"45378 COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR ProFee",45378,0975,,"1,596.5",1197.375,1197.375
,,,,,,,,,,,,,,,,,45383 COLONOSCOPY W CAUTERIZATION ProFee,,0960,,"1,977.9",1483.425,1483.425
,,,,,,,,,,,,,,,,,"45385 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE ProFee",45385,0960,,"2,107",1580.25,1580.25
,,,,,,,,,,,,,,,,,"45398 COLONOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS) ProFee",45398,0960,,"2,132.3",1599.225,1599.225
,,,,,,,,,,,,,,,,,45915 REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA ProFee,45915,0960,,"1,065.1",798.825,798.825
,,,,,,,,,,,,,,,,,46020 PLACEMENT OF SETON ProFee,46020,0960,,935,701.25,701.25
,,,,,,,,,,,,,,,,,46040 INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE) ProFee,46040,0960,,"1,805.9",1354.425,1354.425
,,,,,,,,,,,,,,,,,"46050 INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL ProFee",46050,0960,,931.7,698.775,698.775
,,,,,,,,,,,,,,,,,"46083 INCISION OF THROMBOSED HEMORRHOID, EXTERNAL ProFee",46083,0960,,820.3,615.225,615.225
,,,,,,,,,,,,,,,,,"46221 HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S) ProFee",46221,0960,,"1,104.7",828.525,828.525
,,,,,,,,,,,,,,,,,"46230 EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS ProFee",46230,0960,,"1,066.2",799.65,799.65
,,,,,,,,,,,,,,,,,"46255 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; ProFee",46255,0960,,"1,780.6",1335.45,1335.45
,,,,,,,,,,,,,,,,,"46260 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; ProFee",46260,0960,,"1,977.9",1483.425,1483.425
,,,,,,,,,,,,,,,,,46270 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS ProFee,46270,0960,,"1,712.3",1284.225,1284.225
,,,,,,,,,,,,,,,,,46275 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC ProFee,46275,0960,,"1,891.9",1418.925,1418.925
,,,,,,,,,,,,,,,,,"46600 ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN ProFee",46600,0960,,393.7,295.275,295.275
,,,,,,,,,,,,,,,,,"46924 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPE ProFee",46924,0960,,492.9,369.675,369.675
,,,,,,,,,,,,,,,,,"46940 CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF ANAL SPHINCTER (SEPARATE P ProFee",46940,0960,,"1,131.2",848.4,848.4
,,,,,,,,,,,,,,,,,"46946 HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID C ProFee",46946,0960,,"1,003.3",752.475,752.475
,,,,,,,,,,,,,,,,,"47100 BIOPSY OF LIVER, WEDGE ProFee",47100,0975,,"2,319.9",1739.925,1739.925
,,,,,,,,,,,,,,,,,"47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY ProFee",47562,0960,,"2,405.7",1804.275,1804.275
,,,,,,,,,,,,,,,,,"47563 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY ProFee",47563,0960,,"2,454.2",1840.65,1840.65
,,,,,,,,,,,,,,,,,47600 CHOLECYSTECTOMY; ProFee,47600,0960,,"3,829.1",2871.825,2871.825
,,,,,,,,,,,,,,,,,47605 CHOLECYSTECTOMY; WITH CHOLANGIOGRAPHY ProFee,47605,0960,,"4,391.4",3293.55,3293.55
,,,,,,,,,,,,,,,,,47610 CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; ProFee,47610,0960,,"4,899.6",3674.7,3674.7
,,,,,,,,,,,,,,,,,47801 PLACEMENT OF CHOLEDOCHAL STENT ProFee,47801,0975,,"3,060.6",2295.45,2295.45
,,,,,,,,,,,,,,,,,"49000 EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR WITHOUT BIOPSY(S) (SEPARATE PROC ProFee",49000,0960,,"2,777.3",2082.975,2082.975
,,,,,,,,,,,,,,,,,49002 REOPENING OF RECENT LAPAROTOMY ProFee,49002,0960,,"4,100.3",3075.225,3075.225
,,,,,,,,,,,,,,,,,"49203 EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MO ProFee",49203,0960,,"4,770.6",3577.95,3577.95
,,,,,,,,,,,,,,,,,"49204 EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MO ProFee",49204,0960,,"6,132.1",4599.075,4599.075
,,,,,,,,,,,,,,,,,"49320 LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION ProFee",49320,0960,,"1,977.9",1483.425,1483.425
,,,,,,,,,,,,,,,,,"49321 LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE) ProFee",49321,0960,,"1,242.6",931.95,931.95
,,,,,,,,,,,,,,,,,"49322 LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR ProFee",49322,0960,,"1,325.2",993.9,993.9
,,,,,,,,,,,,,,,,,"49505 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE ProFee",49505,0960,,"1,904.1",1428.075,1428.075
,,,,,,,,,,,,,,,,,"49507 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED ProFee",49507,0975,,"2,617.4",1963.05,1963.05
,,,,,,,,,,,,,,,,,"49520 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE ProFee",49520,0960,,"2,617.4",1963.05,1963.05
,,,,,,,,,,,,,,,,,"49521 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED ProFee",49521,0960,,"2,576.6",1932.45,1932.45
,,,,,,,,,,,,,,,,,49560 REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; REDUCIBLE ProFee,49560,0960,,"2,737.6",2053.2,2053.2
,,,,,,,,,,,,,,,,,49561 REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR STRANGULATED ProFee,49561,0960,,"4,186.3",3139.725,3139.725
,,,,,,,,,,,,,,,,,"49587 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED ProFee",49587,0960,,"3,659.3",2744.475,2744.475
,,,,,,,,,,,,,,,,,"49650 LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA ProFee",49650,0960,,"1,534.7",1151.025,1151.025
,,,,,,,,,,,,,,,,,"49651 LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA ProFee",49651,0960,,"1,995.6",1496.7,1496.7
,,,,,,,,,,,,,,,,,"49652 LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INC ProFee",49652,0960,,"2,678.1",2008.575,2008.575
,,,,,,,,,,,,,,,,,"49653 LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INC ProFee",49653,0960,,"3,339.6",2504.7,2504.7
,,,,,,,,,,,,,,,,,"49654 LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFOR ProFee",49654,0960,,"3,045.1",2283.825,2283.825
,,,,,,,,,,,,,,,,,"49655 LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFOR ProFee",49655,0960,,"3,718.8",2789.1,2789.1
,,,,,,,,,,,,,,,,,"51865 CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; COMPLICATED ProFee",51865,0960,,"2,169.8",1627.35,1627.35
,,,,,,,,,,,,,,,,,"51992 LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETI ProFee",51992,0960,,"3,199.5",2399.625,2399.625
,,,,,,,,,,,,,,,,,52000 CYSTOURETHROSCOPY (SEPARATE PROCEDURE) ProFee,52000,0960,,"1,005.5",754.125,754.125
,,,,,,,,,,,,,,,,,52700 TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS ProFee,52700,0960,,"1,588.8",1191.6,1191.6
,,,,,,,,,,,,,,,,,54150 CIRCUMCISION PLATIBE CHARGE,54150,0960,,766.3,574.725,574.725
,,,,,,,,,,,,,,,,,"54160 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; NEONATE (28 ProFee",54160,0960,,"1,045.2",783.9,783.9
,,,,,,,,,,,,,,,,,"54161 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 2 ProFee",54161,0960,,"1,531.5",1148.625,1148.625
,,,,,,,,,,,,,,,,,55100 DRAINAGE OF SCROTAL WALL ABSCESS ProFee,55100,0960,,"1,015.5",761.625,761.625
,,,,,,,,,,,,,,,,,56405 INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS ProFee,56405,0960,,596.5,447.375,447.375
,,,,,,,,,,,,,,,,,56440 MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST ProFee,56440,0960,,"1,478.5",1108.875,1108.875
,,,,,,,,,,,,,,,,,"56442 HYMENOTOMY, SIMPLE INCISION ProFee",56442,0960,,276.8,207.6,207.6
,,,,,,,,,,,,,,,,,56700 PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING ProFee,56700,0960,,"1,087.1",815.325,815.325
,,,,,,,,,,,,,,,,,"56810 PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE) ProFee",56810,0960,,971.4,728.55,728.55
,,,,,,,,,,,,,,,,,"57065 DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSU ProFee",57065,0960,,882,661.5,661.5
,,,,,,,,,,,,,,,,,57100 BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE) ProFee,57100,0960,,231.6,173.7,173.7
,,,,,,,,,,,,,,,,,57135 EXCISION OF VAGINAL CYST OR TUMOR ProFee,57135,0960,,352.8,264.6,264.6
,,,,,,,,,,,,,,,,,"57200 COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) ProFee",57200,0960,,"1,123.5",842.625,842.625
,,,,,,,,,,,,,,,,,"57240 ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE ProFee",57240,0960,,"2,907.4",2180.55,2180.55
,,,,,,,,,,,,,,,,,"57250 POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY ProFee",57250,0960,,"2,917.3",2187.975,2187.975
,,,,,,,,,,,,,,,,,57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY; ProFee,57260,0960,,"3,606.4",2704.8,2704.8
,,,,,,,,,,,,,,,,,57400 DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL) ProFee,57400,0960,,615.2,461.4,461.4
,,,,,,,,,,,,,,,,,"57420 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; ProFee",57420,0960,,586.6,439.95,439.95
,,,,,,,,,,,,,,,,,"57421 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERV ProFee",57421,0960,,840.1,630.075,630.075
,,,,,,,,,,,,,,,,,57452 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; ProFee,57452,0960,,540.3,405.225,405.225
,,,,,,,,,,,,,,,,,57455 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX ProFee,57455,0960,,770.7,578.025,578.025
,,,,,,,,,,,,,,,,,57456 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH ENDOCERVICAL CURETTAGE ProFee,57456,0960,,706.8,530.1,530.1
,,,,,,,,,,,,,,,,,57461 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATI ProFee,57461,0960,,"1,304.4",978.3,978.3
,,,,,,,,,,,,,,,,,"57500 BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FUL ProFee",57500,0960,,623,467.25,467.25
,,,,,,,,,,,,,,,,,57505 ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE) ProFee,57505,0960,,383.7,287.775,287.775
,,,,,,,,,,,,,,,,,"57511 CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT ProFee",57511,0960,,785,588.75,588.75
,,,,,,,,,,,,,,,,,"57520 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETT ProFee",57520,0960,,"1,133.4",850.05,850.05
,,,,,,,,,,,,,,,,,"57522 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETT ProFee",57522,0960,,927.3,695.475,695.475
,,,,,,,,,,,,,,,,,"58120 DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL) ProFee",58120,0960,,"1,464.2",1098.15,1098.15
,,,,,,,,,,,,,,,,,"58140 MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TO ProFee",58140,0960,,"4,002.1",3001.575,3001.575
,,,,,,,,,,,,,,,,,"58146 MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR ProFee",58146,0960,,"5,055.1",3791.325,3791.325
,,,,,,,,,,,,,,,,,"58150 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), ProFee",58150,0960,,"4,337.3",3252.975,3252.975
,,,,,,,,,,,,,,,,,"58210 RADICAL ABDOMINAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-A ProFee",58210,0960,,"6,603",4952.25,4952.25
,,,,,,,,,,,,,,,,,"58260 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; ProFee",58260,0960,,"3,608.6",2706.45,2706.45
,,,,,,,,,,,,,,,,,"58262 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY( ProFee",58262,0960,,"4,027.5",3020.625,3020.625
,,,,,,,,,,,,,,,,,"58263 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY( ProFee",58263,0960,,"4,335.1",3251.325,3251.325
,,,,,,,,,,,,,,,,,"58270 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE ProFee",58270,0960,,"3,314.2",2485.65,2485.65
,,,,,,,,,,,,,,,,,"58290 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; ProFee",58290,0960,,"4,319.6",3239.7,3239.7
,,,,,,,,,,,,,,,,,"58291 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OV ProFee",58291,0960,,"4,678",3508.5,3508.5
,,,,,,,,,,,,,,,,,"58292 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OV ProFee",58292,0960,,"4,936",3702,3702
,,,,,,,,,,,,,,,,,"58350 CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS ProFee",58350,0960,,501.7,376.275,376.275
,,,,,,,,,,,,,,,,,"58356 ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE, INCLUDING ENDOMETRIAL CURETTAGE, WH ProFee",58356,0960,,"6,438.6",4828.95,4828.95
,,,,,,,,,,,,,,,,,"58540 HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) ProFee",58540,0960,,"3,963.6",2972.7,2972.7
,,,,,,,,,,,,,,,,,"58545 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGH ProFee",58545,0960,,"4,335.1",3251.325,3251.325
,,,,,,,,,,,,,,,,,"58546 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAM ProFee",58546,0960,,"4,932.6",3699.45,3699.45
,,,,,,,,,,,,,,,,,"58550 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; ProFee",58550,0960,,"3,853.3",2889.975,2889.975
,,,,,,,,,,,,,,,,,"58552 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOV ProFee",58552,0960,,"4,284.4",3213.3,3213.3
,,,,,,,,,,,,,,,,,"58553 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; ProFee",58553,0960,,"4,059.4",3044.55,3044.55
,,,,,,,,,,,,,,,,,"58554 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH ProFee",58554,0960,,"4,735.3",3551.475,3551.475
,,,,,,,,,,,,,,,,,"58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) ProFee",58555,0960,,"1,162.1",871.575,871.575
,,,,,,,,,,,,,,,,,"58558 HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH ProFee",58558,0960,,"1,546.9",1160.175,1160.175
,,,,,,,,,,,,,,,,,"58559 HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD) ProFee",58559,0960,,"1,503.9",1127.925,1127.925
,,,,,,,,,,,,,,,,,"58560 HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD) ProFee",58560,0960,,"1,699",1274.25,1274.25
,,,,,,,,,,,,,,,,,"58561 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA ProFee",58561,0960,,"2,402.4",1801.8,1801.8
,,,,,,,,,,,,,,,,,"58563 HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROS ProFee",58563,0960,,"7,445.3",5583.975,5583.975
,,,,,,,,,,,,,,,,,"58600 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, UNILATERA ProFee",58600,0960,,"1,496.2",1122.15,1122.15
,,,,,,,,,,,,,,,,,"58605 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, POSTPARTU ProFee",58605,0960,,"1,347.3",1010.475,1010.475
,,,,,,,,,,,,,,,,,58611 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT THE TIME OF CESAREAN DELIVER ProFee,58611,0960,,423.4,317.55,317.55
,,,,,,,,,,,,,,,,,"58615 OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) VAGINAL OR SUPR ProFee",58615,0960,,"1,148.8",861.6,861.6
,,,,,,,,,,,,,,,,,"58660 LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE ProFee",58660,0960,,"2,931.6",2198.7,2198.7
,,,,,,,,,,,,,,,,,"58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTO ProFee",58661,0960,,"2,809.2",2106.9,2106.9
,,,,,,,,,,,,,,,,,"58662 LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VI ProFee",58662,0960,,"3,077.2",2307.9,2307.9
,,,,,,,,,,,,,,,,,"58670 LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION) ProFee",58670,0960,,"2,552.4",1914.3,1914.3
,,,,,,,,,,,,,,,,,"58671 LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR FALOPE ProFee",58671,0960,,"1,591",1193.25,1193.25
,,,,,,,,,,,,,,,,,"58673 LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY) ProFee",58673,0960,,"3,499.4",2624.55,2624.55
,,,,,,,,,,,,,,,,,"58700 SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) ProFee",58700,0960,,"3,084.8",2313.6,2313.6
,,,,,,,,,,,,,,,,,"58740 LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) ProFee",58740,0960,,"2,095.9",1571.925,1571.925
,,,,,,,,,,,,,,,,,"58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; ProFee",58940,0960,,"2,124.6",1593.45,1593.45
,,,,,,,,,,,,,,,,,59020 FETAL CONTRACTION STRESS TEST ProFee,59020,0987,,88.2,66.15,66.15
,,,,,,,,,,,,,,,,,59025 FETAL NONSTRESS ProFee,59025,0987,,71.8,53.85,53.85
,,,,,,,,,,,,,,,,,"59120 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGECTOMY AND ProFee",59120,0960,,"3,164.2",2373.15,2373.15
,,,,,,,,,,,,,,,,,59151 LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY ProFee,59151,0960,,"3,057.3",2292.975,2292.975
,,,,,,,,,,,,,,,,,"59160 CURETTAGE, POSTPARTUM ProFee",59160,0975,,"1,019.9",764.925,764.925
,,,,,,,,,,,,,,,,,"59300 EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING ProFee",59300,0960,,"1,038.6",778.95,778.95
,,,,,,,,,,,,,,,,,"59320 CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL ProFee",59320,0960,,831.3,623.475,623.475
,,,,,,,,,,,,,,,,,"59400 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY (WITH OR WITHOUT EP ProFee",59400,0960,,"3,596.4",2697.3,2697.3
,,,,,,,,,,,,,,,,,59409 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); ProFee,59409,0975,,"1,807.1",1355.325,1355.325
,,,,,,,,,,,,,,,,,59410 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); INCLUDING POSTPARTU ProFee,59410,0975,,"2,050.7",1538.025,1538.025
,,,,,,,,,,,,,,,,,59414 DELIVERY OF PLACENTA (SEPARATE PROCEDURE) ProFee,59414,0960,,583.3,437.475,437.475
,,,,,,,,,,,,,,,,,59425 ANTEPARTUM CARE ONLY; 4-6 VISITS ProFee,59425,0960,,"1,669.2",1251.9,1251.9
,,,,,,,,,,,,,,,,,59426 ANTEPARTUM CARE ONLY; 7 OR MORE VISITS ProFee,59426,0960,,"2,887.5",2165.625,2165.625
,,,,,,,,,,,,,,,,,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE) ProFee,59430,0960,,301.1,225.825,225.825
,,,,,,,,,,,,,,,,,"59510 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN DELIVERY, AND POSTPARTUM CA ProFee",59510,0960,,"4,072.7",3054.525,3054.525
,,,,,,,,,,,,,,,,,59514 CESAREAN DELIVERY ONLY; ProFee,59514,0975,,"2,140",1605,1605
,,,,,,,,,,,,,,,,,59515 CESAREAN DELIVERY ONLY; INCLUDING POSTPARTUM CARE ProFee,59515,0975,,"2,449.8",1837.35,1837.35
,,,,,,,,,,,,,,,,,"59610 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY (WITH OR WITHOUT EP ProFee",59610,0960,,"8,630.4",6472.8,6472.8
,,,,,,,,,,,,,,,,,"59612 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOTOMY AN ProFee",59612,0960,,"3,640.5",2730.375,2730.375
,,,,,,,,,,,,,,,,,"59614 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOTOMY AN ProFee",59614,0960,,"4,481.8",3361.35,3361.35
,,,,,,,,,,,,,,,,,"59618 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN DELIVERY, AND POSTPARTUM CA ProFee",59618,0960,,"9,287.5",6965.625,6965.625
,,,,,,,,,,,,,,,,,"59620 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN D ProFee",59620,0960,,"3,816.9",2862.675,2862.675
,,,,,,,,,,,,,,,,,"59622 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN D ProFee",59622,0960,,"5,136.6",3852.45,3852.45
,,,,,,,,,,,,,,,,,"59812 TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY ProFee",59812,0975,,588.8,441.6,441.6
,,,,,,,,,,,,,,,,,"59820 TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER ProFee",59820,0975,,627.4,470.55,470.55
,,,,,,,,,,,,,,,,,"59821 TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER ProFee",59821,0975,,669.3,501.975,501.975
,,,,,,,,,,,,,,,,,"59830 TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY ProFee",59830,0960,,"1,911.8",1433.85,1433.85
,,,,,,,,,,,,,,,,,"59855 INDUCED ABORTION, BY 1 OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHO ProFee",59855,0960,,"1,494",1120.5,1120.5
,,,,,,,,,,,,,,,,,"62273 INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH ProFee",62273,0960,,819.3,614.475,614.475
,,,,,,,,,,,,,,,,,"62320 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC ProFee",62320,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"62322 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC ProFee",62322,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"62324 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMIT ProFee",62324,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"62326 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMIT ProFee",62326,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"64415 INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE ProFee",64415,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"64425 INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES ProFee",64425,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE ProFee",64447,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"69110 EXCISION EXTERNAL EAR; PARTIAL, SIMPLE REPAIR ProFee",69110,0960,,"1,604.2",1203.15,1203.15
,,,,,,,,,,,,,,,,,99100 ANES EXTREME AGE <1&>70YR ProFee,99100,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,99140 EMERGENCY CONDITIONS ProFee,99140,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,99217 OBSERVATION CARE DISCHARGE MANAGEMENT ProFee,99217,0987,,178.6,133.95,133.95
,,,,,,,,,,,,,,,,,99218 LEVEL 1: DETAILED HX/EXAM: STRAIGHTFORWARD 30 MIN ProFee,99218,0987,,217.3,162.975,162.975
,,,,,,,,,,,,,,,,,99219 LEVEL 2: COMP HX/EXAM: MODERATE 50 MIN ProFee,99219,0987,,296.7,222.525,222.525
,,,,,,,,,,,,,,,,,99220 LEVEL 3: COMP HX/EXAM: HIGH 70 MIN ProFee,99220,0987,,371.6,278.7,278.7
,,,,,,,,,,,,,,,,,99221 LEVEL 1 ADMIT STRAIGHTFORWARD 30 MIN ProFee,99221,0987,,240.4,180.3,180.3
,,,,,,,,,,,,,,,,,99231 LEVEL 1 VISIT STABLE IMPROVING 15 MIN ProFee,99231,0987,,123.5,92.625,92.625
,,,,,,,,,,,,,,,,,99232 LEVEL 2 VISIT MINOR COMPLICATION 25 MIN ProFee,99232,0987,,171,128.25,128.25
,,,,,,,,,,,,,,,,,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 35 MIN ProFee,99233,0987,,257,192.75,192.75
,,,,,,,,,,,,,,,,,99253 INTL INPT CNSLT 55 MINS/LOW ProFee,99253,0987,,348.4,261.3,261.3
,,,,,,,,,,,,,,,,,99254 INTL INPT CNSLT 80MIN/MOD ProFee,99254,0987,,434.4,325.8,325.8
,,,,,,,,,,,,,,,,,99281 BRIEF SERVICE ProFee,99281,0981,,83.8,62.85,62.85
,,,,,,,,,,,,,,,,,99282 ED PF - Level 2,99282,0981,,176.4,132.3,132.3
,,,,,,,,,,,,,,,,,99291 ED PF - CRITICAL CARE Initial,99291,0981,,602,451.5,451.5
,,,,,,,,,,,,,,,,,99292 ED PF CRITICAL CARE ADDL',99292,0981,,302.1,226.575,226.575
,,,,,,,,,,,,,,,,,99304 ADMIT LOW 25 MIN ProFee,99304,0960,,415.7,311.775,311.775
,,,,,,,,,,,,,,,,,99305 ADMIT MODERATE 35 MIN ProFee,99305,0960,,593.2,444.9,444.9
,,,,,,,,,,,,,,,,,99306 ADMIT HIGH 45 MIN ProFee,99306,0960,,759.7,569.775,569.775
,,,,,,,,,,,,,,,,,99307 VISIT LOW 10 MIN ProFee,99307,0960,,202.9,152.175,152.175
,,,,,,,,,,,,,,,,,99308 VISIT MODERATE 15 MIN ProFee,99308,0960,,314.3,235.725,235.725
,,,,,,,,,,,,,,,,,99309 VISIT MOD/HIGH 25 MIN ProFee,99309,0960,,414.6,310.95,310.95
,,,,,,,,,,,,,,,,,99310 VISIT HIGH 35 MIN ProFee,99310,0960,,617.4,463.05,463.05
,,,,,,,,,,,,,,,,,99315 SWINGBED DIS <30 MINS ProFee,99315,0960,,333,249.75,249.75
,,,,,,,,,,,,,,,,,99316 SWINGBED DIS >30 MINS ProFee,99316,0960,,481.9,361.425,361.425
,,,,,,,,,,,,,,,,,99356 IF OVER A FULL HOUR ADD TO THE ADMIT CODE ProFee,99356,0960,,507.2,380.4,380.4
,,,,,,,,,,,,,,,,,99357 EACH ADDITIONAL ½ HOUR AFTER 1ST HOUR ProFee,99357,0960,,508.3,381.225,381.225
,,,,,,,,,,,,,,,,,99460 INITAL NEWBORN E/M ProFee,99460,0987,,204.1,153.075,153.075
,,,,,,,,,,,,,,,,,99462 SBSQ NB EM PER DAY HOSP ProFee,99462,0987,,87.2,65.4,65.4
,,,,,,,,,,,,,,,,,"99463 INI CARE,ADM/DS SAME DY ProFee",99463,0987,,211.7,158.775,158.775
,,,,,,,,,,,,,,,,,99464 ATTENDANCE AT DELIVERY OF NEWBORN ProFee,99464,0987,,211.7,158.775,158.775
,,,,,,,,,,,,,,,,,ANESTHESIA PRO FEE CHARGE,,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,99135 ANES QUALIFYING CIRCUMSTANCES FOR ANESTHESIA ProFee,99135,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE ProFee,31500,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,36410 VNPNXR 3 YEARS/> PHYS/QHP SKILL ProFee,36410,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,99465 NEWBORN RESUSCITATION CHARGE ProFee,99465,0960,,412.4,309.3,309.3
,,,,,,,,,,,,,,,,,00100 ANES SALIVARY GLAND ProFee,00100,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00120 ANES EXTERNAL AND INNER EAR ProFee,00120,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00124 ANES EXTERNAL MIDDLE & INNER EAR W/BX OTOSCOPY ProFee,00124,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00126 ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY ProFee,00126,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00140 ANESTHESIA EYE NOT OTHERWISE SPECIFIED ProFee,00140,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00322 ANES ESOPH THYRD LARX TRACH & LYMPH NCK BX THYRD ProFee,00322,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00350 ANESTHESIA MAJOR VESSELS NECK NOS ProFee,00350,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00400 ANES INTEG EXTREMITIES ANT TRUNK & PERINEUM NOS ProFee,00400,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00404 ANESTHESIA RADICAL/MODIFIED RADICAL BREAST ProFee,00404,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00406 ANES RADICAL/MODIFIED RADICAL BREAST W/NODES ProFee,00406,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00520 ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY NOS ProFee,00520,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00522 ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA ProFee,00522,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00524 ANESTHESIA CLOSED CHEST PNEUMOCENTESIS ProFee,00524,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00530 ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION ProFee,00530,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00700 ANESTHESIA UPPER ANTERIOR ABDOMINAL WALL NOS ProFee,00700,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00731 ANESTHESIA UPPER GI ENDOSCOPIC PX NOS ProFee,00731,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00732 ANESTHESIA UPPER GI ENDOSCOPIC PX ERCP ProFee,00732,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00750 ANESTHESIA HERNIA REPAIR UPPER ABDOMEN NOS ProFee,00750,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00752 ANES HRNA RPR UPR ABD LMBR&VENTRAL HERNIA&DEHISC ProFee,00752,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00756 ANES HRNA REPAIR UPR ABD TABDL RPR DIPHRG HRNA ProFee,00756,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00790 ANES INTRAPERITONEAL UPPER ABDOMEN W/LAPS NOS ProFee,00790,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00792 ANES LAPS PARTIAL HEPATECTOMY W/MGMT LIVER HEMOR ProFee,00792,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00800 ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL NOS ProFee,00800,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00802 ANES LOWER ANT ABDOMINAL WALL PANNICULECTOMY ProFee,00802,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00811 ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS ProFee,00811,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00812 ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC ProFee,00812,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00813 ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX ProFee,00813,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00820 ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL ProFee,00820,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00830 ANESTHESIA HERNIA REPAIR LOWER ABDOMEN NOS ProFee,00830,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00840 ANESTHESIA INTRAPERITONEAL LOWER ABD W/LAPS NOS ProFee,00840,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00848 ANES IPER LOWER ABD W/LAPS PELVIC EXENTERATION ProFee,00848,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00851 ANES IPER LWR ABD W/LAPS TUBAL LIGATION/TRANSECT ProFee,00851,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00864 ANES XTRPRTL LWER ABD W/URINARY TRACT TOT CYSTEC ProFee,00864,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00902 ANESTHESIA ANORECTAL PROCEDURE ProFee,00902,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00920 ANESTHESIA MALE GENITALIA INCL OPEN URETHRAL PX ProFee,00920,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00921 ANES VASECTOMY UNI/BI INCL OPEN URETHRAL PX ProFee,00921,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00924 ANES UNDSCND TESTIS UNI/BI INCL OPEN URTL PX ProFee,00924,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00928 ANES RAD ORCHIECTOMY ABDOMINAL INCL OPN URTL ProFee,00928,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00948 ANESTHESIA CERVICAL CERCLAGE INCLUDING BIOPSY ProFee,00948,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00950 ANESTHESIA CULDOSCOPY INCLUDING BIOPSY ProFee,00950,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00952 ANES HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX ProFee,00952,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01490 ANES LOWER LEG CAST APPLICATION REMOVAL/REPAIR ProFee,01490,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01710 ANES NRV MUSC TDN FSCA&BRS UPR ARM/ELBOW NOS ProFee,01710,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01810 ANES NERVE MUSCLE TDN FASCIA&BURSA FOREARM WRIST ProFee,01810,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01850 ANESTHESIA VEINS FOREARM WRIST & HAND NOS ProFee,01850,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01860 ANES FOREARM WRIST/HAND CAST APPL RMVL/REPAIR ProFee,01860,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01966 ANESTHESIA INDUCED ABORTION ProFee,01966,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,01999 UNLISTED ANESTHESIA PROCEDURE ProFee,01999,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,36556 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> ProFee,36556,0975,,139,104.25,104.25
,,,,,,,,,,,,,,,,,99116 ANES COMPLICJ UTILIZATION TOTAL BODY HYPOTHERMIA ProFee,99116,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00500 ANESTHESIA ESOPHAGUS ProFee,00500,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00770 ANESTHESIA MAJOR ABDOMINAL BLOOD VESSELS ProFee,00770,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00870 ANES XTRPRTL LWR ABD W/URIN TRACT CSTOLITHOTOMY ProFee,00870,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00630 ANESTHESIA LUMBAR REGION NOS ProFee,00630,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00635 ANES DIAGNOSTIC/THERAPEUTIC LUMBAR PUNCTURE ProFee,00635,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00170 ANESTHESIA INTRAORAL WITH BIOPSY NOS ProFee,00170,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00300 ANES INTEG MUSC & NRV HEAD NECK&POSTERIOR TRUNK ProFee,00300,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,00320 ANES ESOPH THYRD LARYNX TRACH & LYMPH NECK 1YR ProFee,00320,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,Anesthesia Professional Fee,,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,90962 HD Visit One per Month,90962,0960,,"1,455.3",1091.475,1091.475
,,,,,,,,,,,,,,,,,90961 HD Visit 2 to 3 per Month,90961,0960,,"1,697.9",1273.425,1273.425
,,,,,,,,,,,,,,,,,90960 HD Visit 4 or More per Month,90960,0960,,"2,255.8",1691.85,1691.85
,,,,,,,,,,,,,,,,,90970 HD Visit for Transient per Day,90970,0960,,121.3,90.975,90.975
,,,,,,,,,,,,,,,,,90962 HD visit 1 per month ProFee,90962,0960,,"1,455.3",1091.475,1091.475
,,,,,,,,,,,,,,,,,90961 HD visit 2-3 per month ProFee,90961,0960,,"1,697.9",1273.425,1273.425
,,,,,,,,,,,,,,,,,90960 HD visit 4 or more per month ProFee,90960,0960,,"2,255.8",1691.85,1691.85
,,,,,,,,,,,,,,,,,90970 HD visit for transient per day ProFee,90970,0960,,121.3,90.975,90.975
,,,,,,,,,,,,,,,,,Remove skin tags add-on.,11201,0975,,46,34.5,34.5
,,,,,,,,,,,,,,,,,Removal of skin tags ,21931,0975,,"3,791.3",2843.475,2843.475
,,,,,,,,,,,,,,,,,"58805 Drainage, ovarian cyst, uni or bil, vaginal",58805,0975,,"1,148.8",861.6,861.6
,,,,,,,,,,,,,,,,,57288 Sling Operation for Stress Incontinence,57288,0975,,"2,016.9",1512.675,1512.675
,,,,,,,,,,,,,,,,,44385 Endoscopic eval. Of small intestinal pouchw/ or w/o specimen(s) by brush./wash.,44385,0975,,199.9,149.925,149.925
,,,,,,,,,,,,,,,,,44388 Fiberoptic colonoscopy via colostomy,44388,0975,,435.7,326.775,326.775
,,,,,,,,,,,,,,,,,44389 Fiberoptic colonoscopy via colostomy for biopsy,44389,0975,,480.4,360.3,360.3
,,,,,,,,,,,,,,,,,44394 Fiberoptic colonoscopy via colostomy w/ removal tumor/polyp/lesion(s) by snare,44394,0975,,631.7,473.775,473.775
,,,,,,,,,,,,,,,,,45381 Colonoscopy beyond splenic flexure w/ directed submucosal injection(s) any substance,45381,0975,,562.3,421.725,421.725
,,,,,,,,,,,,,,,,,"45382 Colonoscopy beyond splenic flexure w/ control of bleeding (eg, inj., cautery, laser, stapler)",45382,0975,,726.5,544.875,544.875
,,,,,,,,,,,,,,,,,45384 Colonoscopy beyond splenic flexure w/ removal tumor/polyp/lesion(s) by hot biopsy forceps/ca,45384,0975,,638.9,479.175,479.175
,,,,,,,,,,,,,,,,,45305 Proctosigmoidoscopy for biopsy,45305,0975,,200.8,150.6,150.6
,,,,,,,,,,,,,,,,,45308 Proctosigmoidoscopy w/ removal tumor/polyp/lesion(s) by hot biopsy forceps/ cautery,45308,0975,,230,172.5,172.5
,,,,,,,,,,,,,,,,,45309 Proctosigmoidoscopy w/ removal tumor/polyp/lesion(s) by snare,45309,0975,,245.2,183.9,183.9
,,,,,,,,,,,,,,,,,45315 Proctosigmoidoscopy w/ removal multi tumors / polyps / lesions by hot biopsy forceps/cautery,45315,0975,,290.7,218.025,218.025
,,,,,,,,,,,,,,,,,76872 Transrectal Ultrasound,76872,0975,,341.2,255.9,255.9
,,,,,,,,,,,,,,,,,45990 Anorectal Exam under anesthesia,45990,0975,,294.5,220.875,220.875
,,,,,,,,,,,,,,,,,"46250 Hemorrhoidectomy, external complete",46250,0975,,865.3,648.975,648.975
,,,,,,,,,,,,,,,,,"46257 Hemorrhoidectomy, simple w/ fissurectomy",46257,0975,,"1,160",870,870
,,,,,,,,,,,,,,,,,"46258 Hemorrhoidectomy w/ fistulectomy, w/ or w/o fissurectomy",46258,0975,,"1,281.1",960.825,960.825
,,,,,,,,,,,,,,,,,46261 Hemorrhoidectomy w/ fissureectomy,46261,0975,,"1,433.6",1075.2,1075.2
,,,,,,,,,,,,,,,,,"46262 Hemorrhoidectomy w/ fistulectomy, w/ or w/o fissurectomy",46262,0975,,"1,520.9",1140.675,1140.675
,,,,,,,,,,,,,,,,,"46220 Papillectomy/excision anal skin tag, simple",46220,0975,,"1,520.9",1140.675,1140.675
,,,,,,,,,,,,,,,,,"46280 Surgical treatment anal fistula, complex, +/- seton",46280,0975,,"1,295",971.25,971.25
,,,,,,,,,,,,,,,,,"46285 Surgical treatment anal fistula, second stage fistulotomy",46285,0975,,"1,137",852.75,852.75
,,,,,,,,,,,,,,,,,46288 Closure of fistula w/ rectal advancement flap,46288,0975,,"1,507",1130.25,1130.25
,,,,,,,,,,,,,,,,,"46606 Anoscopy, Biopsy",46606,0975,,206.8,155.1,155.1
,,,,,,,,,,,,,,,,,46700 Anoplasty,46700,0975,,"1,805.1",1353.825,1353.825
,,,,,,,,,,,,,,,,,46040 I & D of ischiorectal/perirectal abscess,46040,0975,,"1,139.2",854.4,854.4
,,,,,,,,,,,,,,,,,46060 I & D of ischiorectal/intramural abscess with Fistulectomy,46060,0975,,"1,311.7",983.775,983.775
,,,,,,,,,,,,,,,,,57300 Closure of rectovaginal fistula; tansanal,57300,0975,,"1,569.5",1177.125,1177.125
,,,,,,,,,,,,,,,,,46750 Sphincteroplasty,46750,0975,,"1,569.5",1177.125,1177.125
,,,,,,,,,,,,,,,,,46761 Levator muscle imbrication,46761,0975,,"2,525.9",1894.425,1894.425
,,,,,,,,,,,,,,,,,46200 Fissureectomy w/ Sphincterotomy,46200,0975,,893.4,670.05,670.05
,,,,,,,,,,,,,,,,,"11471 Excision of skin & subcutaneous tissue for hidradenitis suppurativa, extensive",11471,0975,,948.3,711.225,711.225
,,,,,,,,,,,,,,,,,"14001 Flap closure, large (>10cm)",14001,0975,,"1,775.3",1331.475,1331.475
,,,,,,,,,,,,,,,,,"14000 Flap closure, small (<10cm)",14000,0975,,"1,363.3",1022.475,1022.475
,,,,,,,,,,,,,,,,,"21555 Flap closure, small (<10cm) Excision tumor, soft tissue, neck, subcuntaneous",21555,0975,,831.2,623.4,623.4
,,,,,,,,,,,,,,,,,46320 Enucleation/excision of external thrombotic hemorrhoid,46320,0975,,306,229.5,229.5
,,,,,,,,,,,,,,,,,"46945 Ligation of int. hemorrhoid, surgical suture",46945,0975,,617.2,462.9,462.9
,,,,,,,,,,,,,,,,,"45150 Division of stricture, rectum",45150,0975,,"1,137.3",852.975,852.975
,,,,,,,,,,,,,,,,,"45190 Dest. Of rectal tumor, transanal approach",45190,0975,,"1,918.5",1438.875,1438.875
,,,,,,,,,,,,,,,,,45905 Dilation of anal sphincter under anesth.,45905,0975,,462.4,346.8,346.8
,,,,,,,,,,,,,,,,,45910 Dilation of rectal stricture under anesth.,45910,0975,,526.3,394.725,394.725
,,,,,,,,,,,,,,,,,45560 Repair of rectocele,45560,0975,,"1,892.4",1419.3,1419.3
,,,,,,,,,,,,,,,,,46947 Stapled Hemorrhoidopexy,46947,0975,,"1,050.9",788.175,788.175
,,,,,,,,,,,,,,,,,"44020 Enterotomy, Small bowel, not duodenum; for exploration/ biopsy/ foreign body",44020,0975,,"2,678.8",2009.1,2009.1
,,,,,,,,,,,,,,,,,"44021 Enterotomy, Small bowel, not duodenum; for decompression (eg. Baker tube)",44021,0975,,"2,687.1",2015.325,2015.325
,,,,,,,,,,,,,,,,,44110 Ex. Lesion(s) small/large bowel not req. anast./ exterioriza/ fistula/ single enterotomy,44110,0975,,"2,338.8",1754.1,1754.1
,,,,,,,,,,,,,,,,,44111 Ex. Lesion(s) small/large bowel not req. anast./ exterioriza/ fistula/ single enterotomy Multi,44111,0975,,"2,709.6",2032.2,2032.2
,,,,,,,,,,,,,,,,,44121 Enterectomy resection small intestine; each add'l resection & anastomosis,44121,0975,,669.1,501.825,501.825
,,,,,,,,,,,,,,,,,44139 Mobilization (take down) of splenic flexure with partial colectomy (w/ resec. Code),44139,0975,,333.9,250.425,250.425
,,,,,,,,,,,,,,,,,44140 Colectomy partial w/ anastomosis,44140,0975,,"3,693.3",2769.975,2769.975
,,,,,,,,,,,,,,,,,44141 Colectomy partial w/ cecostomy or colostomy,44141,0975,,"5,019.5",3764.625,3764.625
,,,,,,,,,,,,,,,,,44144 Colectomy partial w/ colost/ileost & creation mucofistula,44144,0975,,"4,872.9",3654.675,3654.675
,,,,,,,,,,,,,,,,,"44146 Colectomy partial w/ coloproctost., w/ colost. (or ileost.)",44146,0975,,"5,829.4",4372.05,4372.05
,,,,,,,,,,,,,,,,,44150 Colectomy total w/o proctectomy w/ ileostomy or ileoproctostomy,44150,0975,,"5,133.1",3849.825,3849.825
,,,,,,,,,,,,,,,,,44158 Colectomy total w/o proctectomy w/ creation of ileal resevoir (S or J),44158,0975,,"6,183.6",4637.7,4637.7
,,,,,,,,,,,,,,,,,44160 Right hemicolectomy,44160,0975,,"3,418.3",2563.725,2563.725
,,,,,,,,,,,,,,,,,"44312 Revision of Ileostomy, simple",44312,0975,,"1,628.6",1221.45,1221.45
,,,,,,,,,,,,,,,,,"44314 Revision of Ileostomy, complicated",44314,0975,,"2,767.8",2075.85,2075.85
,,,,,,,,,,,,,,,,,"44340 Revision of colostomy, simple",44340,0975,,"1,709.4",1282.05,1282.05
,,,,,,,,,,,,,,,,,"44345 Revision of colostomy, complicated reconstruction",44345,0975,,"2,890",2167.5,2167.5
,,,,,,,,,,,,,,,,,44346 Revision of colostomy w/ repair of paracolostomy hernia,44346,0975,,"3,255.1",2441.325,2441.325
,,,,,,,,,,,,,,,,,"44620 Closure of enterostomy, large/small",44620,0975,,"2,388.2",1791.15,1791.15
,,,,,,,,,,,,,,,,,44604 Suture repair of colon,44604,0975,,"2,915.9",2186.925,2186.925
,,,,,,,,,,,,,,,,,44850 Suture of mesentery,44850,0975,,"2,058",1543.5,1543.5
,,,,,,,,,,,,,,,,,45110 MAY,45110,0975,,"5,075",3806.25,3806.25
,,,,,,,,,,,,,,,,,45112 Straight colo-anal,45112,0975,,"5,156.2",3867.15,3867.15
,,,,,,,,,,,,,,,,,45119 Colo-anal pouch,45119,0975,,"5,339.4",4004.55,4004.55
,,,,,,,,,,,,,,,,,45113 Completion proctecotmy w/ ileal pouch,45113,0975,,"5,237.5",3928.125,3928.125
,,,,,,,,,,,,,,,,,45505 Delorme Mucosectomy,45505,0975,,"1,628.9",1221.675,1221.675
,,,,,,,,,,,,,,,,,"45130 Excision of rectal procidentia w/ anast., perineal (Altemier)",45130,0975,,"3,001.4",2251.05,2251.05
,,,,,,,,,,,,,,,,,"45540 Proctopexy, abdominal approach",45540,0975,,"2,918.7",2189.025,2189.025
,,,,,,,,,,,,,,,,,45550 roctopexy w/ sigmoid resection,45550,0975,,"4,039.7",3029.775,3029.775
,,,,,,,,,,,,,,,,,44615 Intestinal stricturoplasty w/ or w/o dilation for obstruction,44615,0975,,"2,956.5",2217.375,2217.375
,,,,,,,,,,,,,,,,,44650 Closure of enteroenteric / enterocolic fistula,44650,0975,,"3,981.4",2986.05,2986.05
,,,,,,,,,,,,,,,,,"44661 Closure of enterovesical fistula, w/ bowel and or bladder resection",44661,0975,,"4,281.2",3210.9,3210.9
,,,,,,,,,,,,,,,,,"47001 Biopsy of liver, needle",47001,0975,,287,215.25,215.25
,,,,,,,,,,,,,,,,,49215 Excision presacral or sacrococcygeal tumor,49215,0975,,"6,109.4",4582.05,4582.05
,,,,,,,,,,,,,,,,,49255 Omentectomy,49255,0975,,"2,175.4",1631.55,1631.55
,,,,,,,,,,,,,,,,,"49565 Repair of ventral hernia, recurrent",49565,0975,,"2,109.8",1582.35,1582.35
,,,,,,,,,,,,,,,,,"49566 Repair of ventral hernia, recurrent, incarerated or strangulated",49566,0975,,"2,577.2",1932.9,1932.9
,,,,,,,,,,,,,,,,,49568 Implantation of mesh or other prosthesis for incisional hernia repair,49568,0975,,738,553.5,553.5
,,,,,,,,,,,,,,,,,49900 Suture abd wall for evisceration/ dehisce,49900,0975,,"2,239.4",1679.55,1679.55
,,,,,,,,,,,,,,,,,49905 Omental Flap,49905,0975,,975.8,731.85,731.85
,,,,,,,,,,,,,,,,,"44202 Lap sm bowel resection, single",44202,0975,,"3,809.4",2857.05,2857.05
,,,,,,,,,,,,,,,,,"44203 Lap sm bowel resection, each add'l",44203,0975,,662.4,496.8,496.8
,,,,,,,,,,,,,,,,,44207 Lap LAR,44207,0975,,"5,016.1",3762.075,3762.075
,,,,,,,,,,,,,,,,,44210 Lap subtotal colectomy,44210,0975,,"4,904.9",3678.675,3678.675
,,,,,,,,,,,,,,,,,49010 Laparoscopic exploration behind abdomen,49010,0975,,"2,556.6",1917.45,1917.45
,,,,,,,,,,,,,,,,,44188 Lap Surgical colostomy or skin level cecostomy,44188,0975,,"3,365",2523.75,2523.75
,,,,,,,,,,,,,,,,,45402 Lap proctopexy w/ sigmoid resection,45402,0975,,"4,181",3135.75,3135.75
,,,,,,,,,,,,,,,,,"44213 Lap mobilization (take down) of splenic flexure,with partial colectomy (w/ resec. Code)",44213,0975,,519.6,389.7,389.7
,,,,,,,,,,,,,,,,,49585 Umbilical Herniorraphy,49585,0975,,"1,218.3",913.725,913.725
,,,,,,,,,,,,,,,,,49329 Unlisted laparoscopic procedure,49329,0960,,896.7,672.525,672.525
,,,,,,,,,,,,,,,,,"12042 Repair, intermediate, wound of neck, hands, feet and/or ext. genitalia 2.6 cm - 7.5 cm",12042,0960,,538.2,403.65,403.65
,,,,,,,,,,,,,,,,,"59412 External cephalic version, with or w/o tocolysis",59412,0960,,"1,989.9",1492.425,1492.425
,,,,,,,,,,,,,,,,,"21554 Excision, tumor, soft tissue, neck or anterior thorax, subfascial, 5 cm or greater",21554,0960,,279.5,209.625,209.625
,,,,,,,,,,,,,,,,,"43840 Gastrorrhaphy, suture of perforated duodenal or gastric ulcer",43840,0960,,"3,719.6",2789.7,2789.7
,,,,,,,,,,,,,,,,,"99156 Moderate sedation, other physician, initial 15 minutes, 5/> yrs",99156,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,58562 Hysteroscopy removal FB,58562,0975,,614.8,461.1,461.1
,,,,,,,,,,,,,,,,,"92960 Cardioversion, elective, electrical conversion of arrhythmia, external",92960,0960,,301.2,225.9,225.9
,,,,,,,,,,,,,,,,,"59870 Uterine evac & curettage, hydatiform mole",59870,0975,,"1,374.2",1030.65,1030.65
,,,,,,,,,,,,,,,,,"17003 Destruction lesion, premalignant, second through fourteenth",17003,0983,,5.9,4.425,4.425
,,,,,,,,,,,,,,,,,"56501 Destruction of lesions, vulva",56501,0983,,341.4,256.05,256.05
,,,,,,,,,,,,,,,,,"17110 Destruction, benign lesions other than skin tags, up to 14 lesions",17110,0983,,181.7,136.275,136.275
,,,,,,,,,,,,,,,,,00906 ANES Vulvectomy,00906,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"99157 Moderate sedation, other physician, ea add'l 15 minutes, any age",99157,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,"99155 Moderate sedation, other physician, initial 15 minutes, < 5 yrs",99155,0964,,139,104.25,104.25
,,,,,,,,,,,,,,,,,56620 Vulvectomy simple; partial.,56620,0960,,"1,509.3",1131.975,1131.975
,,,,,,,,,,,,,,,,,"58700 Salpingectomy, complete or partial, unilateral or bilateral.",58700,0975,,"2,168",1626,1626
,,,,,,,,,,,,,,,,,"58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral.",58720,0975,,"2,044.9",1533.675,1533.675
,,,,,,,,,,,,,,,,,"51860 Cystorrhaphy, suture of bladder wound, injury or rupture",51860,0975,,"2,049",1536.75,1536.75
,,,,,,,,,,,,,,,,,"58925 Removal, ovarian cyst(s)",58925,0975,,"1,950.2",1462.65,1462.65
,,,,,,,,,,,,,,,,,"24076 Excision, tumor, soft tissue upper arm or elbow, subfascial < 5 cm",24076,0960,,"1,384.1",1038.075,1038.075
,,,,,,,,,,,,,,,,,"24073 Excision, tumor, soft tissue upper arm or elbow, subfascial 5 cm or greater",24073,0960,,"1,760.4",1320.3,1320.3
,,,,,,,,,,,,,,,,,"21552 Excision, tumor, soft tissue of neck or anterior thorax, subcu, 3cm/>",21552,0975,,"1,130.4",847.8,847.8
,,,,,,,,,,,,,,,,,"21014 Exc face tumor, soft tissue, face/scalp, subfascial 2cm/>",21014,0975,,"1,326.6",994.95,994.95
,,,,,,,,,,,,,,,,,"23930 Incision & Drainage, upper arm or elbow area",23930,0975,,549.4,412.05,412.05
,,,,,,,,,,,,,,,,,"58301 Removal, intrauterine device (IUD)",58301,0975,,169.9,127.425,127.425
,,,,,,,,,,,,,,,,,"11982 Removal, non-biodegradable drug delivery implant",11982,0975,,189.5,142.125,142.125
,,,,,,,,,,,,,,,,,59899 Other Procedures for Maternity Care/Delivery,59899,0960,,"2,777.3",2082.975,2082.975
,,,,,,,,,,,,,,,,,56740 Remove vagina gland lesion,56740,0960,,801.9,601.425,601.425
,,,,,,,,,,,,,,,,,"59121 Surgical treatment of ectopic pregnancy, w/o salpingectomy and/or oophorectomy",59121,0960,,"2,035.1",1526.325,1526.325
,,,,,,,,,,,,,,,,,"59136 Surgical treatment of ectopic pregnancy, interstitial, uterine pregnancy w/partial resection o",59136,0960,,"2,242.4",1681.8,1681.8
,,,,,,,,,,,,,,,,,"59150 Laparoscopic treatment of ectopic pregnancy, w/o salpingectomy and/or oophorectomy",59150,0960,,"1,973.5",1480.125,1480.125
,,,,,,,,,,,,,,,,,59871 Remove cerclage suture,59871,0960,,329,246.75,246.75
,,,,,,,,,,,,,,,,,"19020 Incision, breast lesion ProFee",19020,0960,,790.5,592.875,592.875
,,,,,,,,,,,,,,,,,"54700 I&D, epididymis, testis and/or scrotal space",54700,0960,,544.9,408.675,408.675
,,,,,,,,,,,,,,,,,"55040 Excision, hydrocele, unilateral",55040,0960,,866.1,649.575,649.575
,,,,,,,,,,,,,,,,,"49020 Drainage, peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess",49020,0960,,"4,020.5",3015.375,3015.375
,,,,,,,,,,,,,,,,,"49250 Excision, umbilicus",49250,0960,,"1,491",1118.25,1118.25
,,,,,,,,,,,,,,,,,"21011 Excision, tumor, soft tissue of face or scalp, subcu, <2 cm",21011,0960,,655.5,491.625,491.625
,,,,,,,,,,,,,,,,,"21012 Excision, tumor, soft tissue of face or scalp, subcu, 2 cm or greater",21012,0960,,858.3,643.725,643.725
,,,,,,,,,,,,,,,,,"27339 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular), 5 cm or gr",27339,0975,,"1,908.2",1431.15,1431.15
,,,,,,,,,,,,,,,,,"64505 Injection, anesthetic agent; sphenopalatine ganglion;",64505,0975,,241.38,181.035,181.035